Controlled release cgrp delivery composition for cardiovascular and renal indications

ABSTRACT

The present invention provides methods of treating heart failure and improving renal function, and/or preventing the advancement of heart failure into advanced stages, and methods of counteracting ischemia due to a myocardial infarction by providing improved methods of administering a therapeutically effective amount CGRP as a controlled release formulation. The therapies can be administered on an outpatient or inpatient basis and can further be used as maintenance therapies.

BACKGROUND OF TILE INVENTION

1. Field of the Invention

The present invention provides methods for treating heart failureimproving renal function, preventing or delaying the advancement ofheart failure into advanced stages, and counteracting ischemia due to amyocardial infarction by providing improved methods of administering atherapeutically effective amount CGRP as a controlled releaseformulation.

2. Description of the Prior Art

Heart failure is a complex clinical syndrome that can result from anystructural or functional cardiac disorder that impairs the ability ofthe ventricle to fill with or eject blood, and the heart works lessefficiently than it should. Heart failure is characterized by specificsymptoms (e.g., dyspnea and fatigue) which may limit exercise toleranceand signs (e.g., fluid retention) which may lead to pulmonary congestionand peripheral edema. Both abnormalities can impair the functionalcapacity and quality of life of affected individuals, but they may notnecessarily dominate the clinical picture at the same time. Because notall patients have volume overload at the time of initial or subsequentevaluation, the term “heart failure” is preferred over the older term“congestive heart failure.”

The clinical syndrome of heart failure may result from disorders of thepericardium, myocardium, endocardium, or great vessel. For example,common causes of heart failure include: narrowing of the arteriessupplying blood to the heart muscle (coronary heart disease); priorheart attack (myocardial infarction) resulting in scar tissue largeenough to interfere with normal function of the heart; high bloodpressure; heart valve disease due to past rheumatic fever or anabnormality present at birth; primary disease of the heart muscle itself(cardiomyopathy); defects in the heart present at birth (congenitalheart disease) and infection of the heart valves and/or muscle itself(endocarditis and/or myocarditis or pericarditis). The majority ofpatients with heart failure have symptoms due to an impairment of leftventricular function. Each of these disease processes can lead to heartfailure by reducing the strength and efficiency of the heart musclecontraction, by limiting the ability of the heart's pumping chambers tofill with blood due to mechanical problems or impaired diastolicrelaxation, or by filling the chambers with too much blood.

Renal blood flow is also an important factor in the development of theclinical syndrome of heart failure. It is a determinant of someimportant neurohormonal responses and of salt and water retention. Renalblood flow is reduced in patients with HF, and many patients with HFwill also eventually develop renal failure.

There are four stages of heart failure recognized by the AmericanCollege of Cardiology Guidelines for the Evaluation and Management ofChronic Heart Failure in the Adult. Stage A refers to patients who areat high risk for developing heart failure but have no identifiedstructural or functional abnormalities of the heart and have never shownsigns or symptoms of heart failure. If needed, Stage A patients areprescribed ACE inhibitors to lower blood pressure and reduce the heart'swork load. Stage B refers to patients who have developed structuralheart disease strongly associated with the development of heart failurebut have never shown signs or symptoms of heart failure. Stage Bpatients are typically prescribed ACE inhibitors and beta-blockers thatdecrease myocardial oxygen demand and thereby ischemia, and reduce heartrate and cardiac work. Stage C refers to current or prior symptoms ofheart failure associated with underlying structural disease. Managementof HF at Stage C can involve a triple or quadruple drug therapy thatincludes ACE inhibitors, beta-blockers, diuretics, and Digitalis. StageD refers to patients with advanced structural heart disease and markedsymptoms of heart failure at rest despite maximal medical therapy,requiring specialized intervention. Since HF is a terminal condition,mid and end-stage HF (Stages C and D, respectively) treatment focuses onalleviating symptoms and increasing the patient's quality of life suchthat they can continue to live a relatively active lifestyle. Successfulmanagement of the progression of heart failure and effective treatmentsto relieve heart failure symptoms are determined by monitoring increasesin the heart's ejection fraction, decreases in dyspnea, and changes inthe frequency and/or severity of heart failure symptoms. However, whilecurrent end-stage drug therapies such as Dobutamine or Milrinoneincrease the patient's quality of life, they also have been shown toincrease mortality.

It is estimated that about four million people in the United Statessuffer from various degrees of heart failure. Although heart failure isa chronic condition, the disease often requires acute hospital care.Patients are commonly admitted for acute pulmonary congestionaccompanied by serious or severe shortness of breath. Acute care for HFaccounts for the use of more hospital days than any other cardiacdiagnosis, and consumes in excess of seven and one-half billion dollarsin the United States annually.

Current research into the treatment of chronic heart failure is focusedon providing cardioprotection, myocardial tissue salvage by minimizingor reducing infarction size, and preventing reperfusion injury. Manycurrent drug therapies for treating heart failure address specificclinical aspects associated with myocardial infarction, such asanti-platelet/fibrinolytic, anti-inflammatory, and antioxidantactivities. Such drugs include ACE inhibitors to prevent blood vesselconstriction and to increase blood flow to the body, diuretics to removeexcess fluid, beta blockers to reduce heart work load, calcium channelblockers to increase the blood flow through the heart and prevent vesselconstriction, blood thinners to prevent blood clots, and cardiotonics tostrengthen the heart's ability to pump blood. Only a few companies todate are developing new drugs that address tissue salvage, however theeffectiveness of these drugs remains to be established in the clinic. Aswith all drugs, these agents must be taken in doses sufficient to ensuretheir effectiveness. Problematically, however, over-treatment can leadto hypotension, renal impairment, hyponatremia, hypokalemia, worseningheart failure, impaired mental functioning, and other adverseconditions. Surgical treatments include angioplasty, coronary arteryby-pass grafts, valve replacement, pacemakers, internal defibrillators,left ventricular assist devices, and heart transplants.

Heart failure is the number one diagnosis for hospital admissions inpatients over the age of 65. More than $38.1 billion has been spentannually since 1991 on inpatient and outpatient costs and greater than$500 million on drugs to treat HF. The disorder is the underlying reasonfor 12 to 15 million office visits each year and 1.7 to 2.6 millionhospital admissions each year. Because of the hospitalization costsrequired to treat a heart failure patient, the current trend is to getHF patients into outpatient care as soon as possible, often within the48 hours of hospital admission. Specialized outpatient clinics are nowavailable for heart failure patients. The patients typically attend theclinic between one and four times per week to receive intravenousinfusions of a prescribed heart failure therapy until hemodynamicsymptoms improve.

Calcitonin gene-related peptide (“CGRP”) is a 37-amino acid neuropeptidewhich is the most potent naturally occurring vasodilator peptide in thehuman body. CGRP is distributed throughout the central and peripheralnervous systems, and is found in areas that are known to be involved incardiovascular function (Wimalawansa, S., Critical Reviews inNeurobiology, 11:167-239 (1997)). Peripherally, CGRP is found in theheart, particularly in association with the sinoatrial andatrioventricular nodes. In addition, CGRP is found in nerve fibers thatform a dense periadventitial network throughout the peripheral vascularsystem, including the cerebral, coronary, and renal arteries. CGRP hasprominent cardiovascular effects, including vasodilation and positivechronotropic and inotropic effects, which may play an important role innormal cardiovascular function (Wimalawansa, S., Endocrine Reviews,17:208:217 (1996)).

When administered, CGRP has pronounced cardiovascular benefits,including vasodilation, ischemic cardioprotection, reduction ininfarction size due to heart attack, inhibition of platelet aggregationand smooth muscle cell proliferation which can potentially reduce theincidence of restenosis, increased renal function, and overall increasedefficiency of cardiovascular functions. As a result of providingcardioprotection, minimizing reperfusion injury, and reducing infarctionsize, CGRP also promotes myocardial tissue salvage. CGRP also plays arole in regulating inotropy, chronotropy, microvascular permeability,vascular tone, and angiogenesis. CGRP also has significant advantagesover conventional drug treatments. First, CGRP does not produce thepotentially dangerous side effects, toxicity and tolerance associatedwith conventional cardiovascular drugs such as Nitroglycerin, Dobutamineand Natrecor. In fact, CGRP has been reported to down-regulate immuneresponse via inhibition of cytokine release and has been safelyadministered to immuno-suppressed subjects without the induction ofsensitivity. Second, because CGRP has multiple hemodynamic benefits, itcan potentially reduce or eliminate the need for drug cocktails tomaintain specific hemodynamic functions. Third, the biochemical activityof CGRP is mediated through specific receptor binding sites concentratedin the heart, kidneys, and genitalia, and is known to act on twospecific CGRP receptor subtypes located on the surface of theendothelial and smooth muscle cells, respectively. Accordingly, CGRPexhibits virtually no side effects or tolerance when administeredsystemically.

Studies have demonstrated that acute administration of CGRP can resultin increased cardiac performance and reduced systemic resistance in anumber of clinical scenarios. For example, Anand, et al. (J. Am. Coll.Cardiol., 17:208-217 (1991)) reported that short-term IV infusions (10or 20 minutes) of CGRP at rates of 0.8, 3.2, or 16 ng/kg/min (i.e., 56,224, or 1120 ng/min based on a 70 kg subject) produced beneficialhemodynamic effects such as decreased systemic vascular resistance andincrease in cardiac output, with no tachycardia observed. The studyconcluded that at lower doses CGRP behaves as a pure arteriolarvasodilator, where as at the higher dose CGRP acts a mixed vasodilator.Stephenson, et al. (Int. J. Cardiol., 37:407-414 (1992)) reportedadministration of CGRP at a rate of 600 ng/min by either a 48-hourcontinuous IV infusion or 2-8 hour infusions for two consecutive days.In the continuous infusion therapy, infusion was discontinued after 28hours in 3 out of the 6 patients due to nausea, diarrhea, and/or severefacial flushing. On the other hand, the pulsed therapy was welltolerated and was observed to improve hemodynamic functions such as leftventricular function. However, unfavorable side effects of tachycardiaand neurohumoral response were also observed with the pulsed therapy.Sekhar, et al. (Am. J. Cardiol. 67:732-736 (1991) reportedadministration of CGRP at a rate of 8 ng/kg/min (i.e., 560 ng/min basedon a 70 kg subject) by IV infusion for 8 hours. This therapy wasobserved to have beneficial hemodynamic effects such as decreasedpulmonary and systemic arterial pressure, decreased vascular resistanceand increased cardiac output. It was also observed that renal blood flowand glomerular filtration were increased during treatment. However, thehemodynamic effects were lost within 30 minutes of stopping CGRPinfusion.

Chronic HF is a progressive disease. Therefore, therapies that initiallyseek to reduce disease progression while increasing the patient'squality of life and relieving symptoms that exacerbate the condition aredesirable. It would be far more cost effective and much better for thepatient's health if chronic heart failure could be managed andcontrolled by the routine or controlled release administration ofappropriate drug therapy rather than by hospital treatment upon themanifestation of acute symptoms.

SUMMARY OF THE INVENTION

The present invention provides a method for the treatment or preventionof heart failure (“HF”) by administering one or more doses of a CGRPformulation in a manner that will treat the conditions underlying HFwhile minimizing or attenuating deleterious effects commonly associatedwith CGRP such as nausea, diarrhea, severe facial flushing andintermittent tachycardia. More specifically, this invention providesimproved CGRP dosing regimes for patients suffering from or at risk forHF, and a method of treating HF or delaying the progression of HF intomore advanced stages by providing lower dose and longer termadministration of CGRP.

Accordingly, one aspect of this invention provides a method of treatingHF in a patient comprising administering CGRP to the patient such thatcirculating plasma levels of CGRP are sufficient to maintain hemodynamicstability, thereby preventing or delaying exacerbation HF symptoms. Inprior clinical studies using Stage C and D HF patients, effectivecirculating plasma levels of CGRP were administered by intravenousinfusions ranging between 157±26 pg/mL to 186±127 pg/mL (Anand, et al.,1991 and Shekhar, et al., 1991, supra). However, these doses could onlybe administered intravenously for about 12-24 hours before unwanted sideeffects set in and the IV administration had to be discontinued. Incontrast, the methods of the present invention administer CGRP bycontrolled release systems or compositions that maintain circulatingplasma levels of CGRP between about 11±5 pg/mL and 186±127 pg/mL for alength of time that is within the capabilities of the particularcontrolled release delivery system or composition.

In one embodiment, the controlled release composition comprises abiodegradable polymer matrix containing CGRP, wherein CGRP is releasedfrom the polymer matrix in situ by diffusion or dissolution from withinthe polymer matrix and/or by the degradation of the polymeric matrix.The controlled release formulation can also be in film form. In anotherembodiment, the controlled release formulation comprises solidmicroparticles formed from the combination of biodegradable, syntheticpolymers such as poly(lactic acid) (PLA), poly(glycolic acid) (PGA), andcopolymers thereof with CGRP loadings that yield a sustained releaseover a period of time when administered orally, transmucosally,topically or by injection. In further embodiments, the controlledrelease formulations comprise CGRP encapsulated in a liposome or CGRPconjugated to a polymer.

The above-described methods and controlled release compositions canfurther be used for maintenance therapies, preferably using lower dosesor dosing rates of CGRP, after the initial therapy is completed.

This invention further provides prophylactic methods of preventing HF ina patient at risk of HF or slowing the progression or symptoms of HF ina patient suffering from HF. For example, another aspect of thisinvention provides a method of preventing or reducing the risk ofoccurrence of myocardial infarction in a patient, comprisingadministering to a human at risk of having a myocardial infarction acontrolled release CGRP formulation in an amount effective to prevent orreduce the risk of myocardial infarction.

In all of the above-described methods, the amount of CGRP delivered tothe patient depends on the symptoms, stage of HF, degree of severityand/or other medications (e.g., diuretics) being administered to thepatient.

This invention further provides a method of augmenting current HFtherapies comprising administering CGRP according to the dosing regimesof this invention together with one or more addition drugs for HF,wherein CGRP and the additional drug(s) can be administered together,separately and simultaneously, or separately in any order.

This invention further provides a method of counteracting ischemia dueto myocardial infarction in a patient, comprising delivering to saidpatient an amount of CGRP effective to provide cardioprotection,reduction in infarction size, reduction in reperfusion injury,symptomatic relief, and/or prevent exacerbation of symptoms, whereinsaid CGRP is delivered to said patient as a controlled releasecomposition.

Another aspect of this invention comprises a method of improving renalblood flow and glomerular filtration in a patient suffering fromdiminished renal function, comprising administering CGRP to a patient inneed thereof in a manner effective to improve renal blood flow and/orglomerular filtration.

Administering CGRP according to the methods of this invention provides asafer and more effective treatment of acute cardiac ischemia and heartfailure compared to current treatments for HF. Given the advantages incardioprotection, myocardial tissue salvage, cardiac hemodynamicimprovement, and renal function provided by CGRP, the methods of thisinvention have the potential to be powerful frontline weapons in thearsenal of emergency room doctors who are the first to treat patientssuffering from myocardial infarction (MI) upon entry into the healthcare system, and/or an interventional cardiologist who is working tore-establishing blood flow to an ischemic heart using angioplasty orstenting procedures, and/or a cardiologist who is treating mid- toend-stage heart failure patients to provide increased quality of life toterminal patients.

Additional advantages and novel features of this invention shall be setforth in part in the description that follows, and in part will becomeapparent to those skilled in the art upon examination of the followingspecification or may be learned by the practice of the invention. Theadvantages of the invention may be realized and attained by means of theinstrumentalities, combinations, compositions, and methods particularlypointed out in the appended claims.

DETAILED DESCRIPTION OF THE INVENTION

One aspect of this invention provides improved methods for administeringCGRP to a patient having HF in a manner effective to treat or preventHF. The “patient” can be any living organism, including a warm-bloodedmammal such as a human. The treatment according to any of the methods ofthis invention can be administered on an inpatient such as a hospital oremergency room, or in an outpatient setting such as a hospice or homehealth care setting or administration by emergency care personnel to apatient having a myocardial infarction. This invention further providesmethods of improving hemodynamic functions in a patient with HF byproviding improved methods of administering CGRP to the patient ineither an inpatient or outpatient setting.

“Treating HF” as used herein refers to treating any one or more of theconditions underlying HF, including, without limitation, decreasedcardiac contractility, abnormal diastolic compliance, reduced strokevolume, pulmonary congestion, decreased cardiac output, and otherdiminished hemodynamic functions, while minimizing or attenuatingdeleterious effects that may be associated with the long-termadministration of CGRP such as nausea, diarrhea, severe facial flushingand intermittent tachycardia. “Treating HF” also includes relieving orattenuating symptoms associated with HF.

This invention also provides a method of improving the quality of lifein a patient with HF. “Quality of life” refers to one or more of aperson's ability to walk, climb stairs, do errands, work around thehouse, participate in recreational activities, and/or not requiringfrequent rest intermittently during activities, and/or the absence ofsleeping problems or shortness of breath.

For purposes of this invention, a “patient having HF” refers to a personhaving Stage B, Stage C, or Stage D heart failure as classified in theAmerican College of Cardiology Guidelines for the Evaluation andManagement of Chronic Heart Failure in the Adult. While the AmericanCollege of Cardiology Guidelines excluded HF in children, for purposesof this invention the methods are to be considered applicable to anypatient, regardless of age.

More specifically, this invention provides improved methods forproviding effective amounts of CGRP for treating or preventing HF and/orfor improving renal function in a patient. In the treatment of HFaccording to this invention, compositions comprising CGRP alone or incombination with other drugs or therapies will be formulated, dosed, andadministered in a fashion consistent with good medical practice. It isto be understood that the actual dose will depend on the particularfactors of each case. Generally, the dosage required to provide aneffective amount of CGRP or a pharmaceutically acceptable salt thereofis within the ranges disclosed herein and can be adjusted by one ofordinary skill in the art. The dosage will vary depending on theclinical condition of the individual patient (especially the sideeffects of treatment with CGRP alone or in combination with othertherapeutics), the age, health, physical condition, sex, diet andmedical condition of the patient, the severity (i.e., stage) of heartfailure, the route of administration, the site of delivery of CGRP, thetype of drug delivery system that is used, whether CGRP is administeredas part of a drug combination, the scheduling of administration, andother factors known to practitioners. Thus, while individual needs mayvary, determination of optimal ranges for effective amounts of CGRP(alone or in combination with other drugs) within the ranged disclosedherein is within the expertise of those skilled in the art. Accordingly,“effective amounts” of each component for purposes herein are determinedby such considerations and are amounts that improve one or morehemodynamic functions and/or ameliorate on or more deleteriousconditions in HF patients and/or improve the quality of life in HFpatients and/or improve renal function.

The term “hemodynamic functions” includes, but is not limited to, heartrate, right atrial pressure, pulmonary artery pressure, pulmonary arterywedge pressure, systemic arterial pressure, cardiac output (i.e.,cardiac index), stroke volume index, pulmonary vascular resistance, andsystemic vascular resistance.

The term “improved hemodynamic functions” includes, but is not limitedto, increased cardiac output, decreased pulmonary artery wedge pressure,decreased pulmonary vascular resistance, and decreased systemic vascularresistance, increased cardiac contractility, normal diastoliccompliance, increased stroke volume and reduced pulmonary congestion.

The term “afterload” refers to the resistance that the heart has toovercome during every beat to send blood into the aorta. This resistiveforce includes vasoactivity and blood viscosity.

The term “cardiac index” (CI) refers to amount of blood pumped by theheart per minute per meter squared of body surface area.

The term “cardiac output” (CO) refers to the volume of blood pumped bythe heart in one minute. Increased cardiac output can indicate a highcirculating volume. Decreased cardiac output indicates a decrease incirculating volume or a decrease in the strength of ventricularcontraction.

The term “central venous pressure” (CVP) refers to readings that areused to approximate the Right Ventricular End Diastolic Pressure(RVEDP). The RVEDP assesses right ventricular function and general fluidstatus. Low CVP values typically reflect hypovolemia or decreased venousreturn, and high CVP values reflect overhydration, increased venousreturn or right-sided cardiac failure.

The term “change in heart rate” refers to a condition that indicatestachycardia or increased workload.

The term “dyspnea” means shortness of breath. Dyspnea is a primaryclinical endpoint to address efficacy in heart failure treatments.

The term “left ventricular stroke index” (LVSI) refers to the differencein contractile position of the left ventricle from the resting positionto the point of maximum contraction.

The term “mean arterial pressure” (MAP) refers to changes in therelationship between cardiac output (CO) and systemic vascularresistance (SVR) and reflects the arterial pressure in the vesselsperfusing the organs. A low MAP indicates decreased blood flow throughthe organs, and a high MAP indicates an increased cardiac workload.

The term “neurohormone release” refers to a response by the kidneys toincrease renal blood flow by releasing the vasoconstrictingneurohormones norepinephrine, epinephrine, and rennin. These hormonesact to constrict peripheral vasculature adversely affecting the PVR.

The term “preload” refers to the combination of pulmonary blood fillingthe atria and the stretching of myocardial fibers. Preload is regulatedby the variability in intravascular volume. A reduction in volumedecreases preload, whereas an increase in volume increases preload, meanarterial pressure (MAP) and stroke index (SI). Preload occurs duringdiastole.

The term “pulmonary artery pressure” (PA pressure) refers to bloodpressure in the pulmonary artery. Increased pulmonary artery pressuremay indicate a left-to-right cardiac shunt, pulmonary arteryhypertension, COPD, emphysema, pulmonary embolus, pulmonary edema, orleft ventricular failure.

The term “pulmonary capillary wedge pressure” (PCWP or PAWP) refers to apressure are used to approximate LVEDP (left ventricular end diastolicpressure). High PCWP may indicate left ventricle failure, mitral valvepathology, cardiac insufficiency, and/or cardiac compression posthemorrhage. PCWP is a primary clinical endpoint to address efficacy inheart failure treatments.

The term “pulmonary vascular resistance” (PVR) refers to the measurementof resistance or the impediment of the pulmonary vascular bed to bloodflow. An increased PVR is caused by pulmonary vascular disease,pulmonary embolism, pulmonary vasculitis, or hypoxia. A decreased PVR iscaused by medications such as calcium channel blockers, aminophylline orisoproterenol, or by the delivery of O₂.

The term “renal blood flow” (RBF) refers to the measurement of bloodflow into the kidneys. Twenty percent of cardiac output passes throughthe kidneys, which compromise less than 1% of body weight. Increasedrenal blood flow is proportional to increased renal function and urineoutput.

The term “renal glomerular filtration” (RBF) refers to the first step inurine formation as protein-free ultrafiltrate plasma crosses the wallsof the glomerular capillaries. Increased renal blood flow increases flowof plasma across the glomeruli, increasing urine output.

The term “right ventricular pressure” (RV Pressure) refers to a directmeasurement that indicates right ventricular function and general fluidstatus. High RV pressure may indicate pulmonary hypertension, rightventricle failure, or congestive heart failure.

The terms “stroke index” or “stroke volume index” (SI or SVI) are usedinterchangeably and refer to the amount of blood ejected from the heartin one cardiac cycle, relative to Body Surface Area (BSA). SVI ismeasured in milliliters per meter squared per beat. An increased SVI canbe indicative of early septic shock, hyperthermia or hypervolemia, orcan be caused by medications such as dopamine, Dobutamine or Digitalis.A decreased SVI can be caused by CHF, late septic shock, beta-blockersor an MI.

The term “stroke volume” (SV) refers to the amount of blood pumped bythe heart per cardiac cycle, and is measured in milliliters per beat. Adecreased SV may indicate impaired cardiac contractility or valvedysfunction and may result in heart failure. An increased SV can becaused by an increase in circulating volume or an increase in inotropy.

The term “systemic vascular resistance” (SVR refers to the measurementof resistance or impediment of the systemic vascular bed to blood flow.An increase in SVR can be caused by vasoconstrictors, hypovolemia orlate septic shock. A decrease in SVR can be caused by early septicshock, vasodilators, morphine, nitrates or hypercarbia.

A “microgram” (μg) is 1 millionth of a gram, i.e., 10⁻⁶ grams.

A “nanogram” (ng) is 1 billionth of a gram, i.e., 10⁻⁹ grams.

A “picogram” (pg) is 1 trillionth of a gram, i.e., 10⁻¹² grams.

Table 1 provides normal values for the above-described hemodynamicparameters.

TABLE 1 Hemodynamic Parameter Normal Value Blood Pressure Systolic (SBP)90-140 mm Hg Diastolic (DBP) 60-90 mm Hg Mean Arterial Pressure (MAP)70-100 mm Hg Cardiac Index (CI) 2.5-4 L/min/m² Cardiac Output (CO) 4-8L/min Central Venous Pressure (CVP) 2-6 mm Hg Pulmonary Artery Pressure(PA) Systolic: 20-30 mm Hg (PAS) Diastolic: 8-12 mm Hg (PAD) Mean: 25 mmHg (PAM) Pulmonary Capillary Wedge Pressure 4-12 mm Hg (PWCP) PulmonaryVascular Resistance (PVR) 37-250 dynes/sec/cm³ Right VentricularPressure (RV) Systolic-20-30 mm Hg Diastolic 0-5 mm Hg Stroke Index (SI)25-45 mL/m² Systemic Vascular Resistance (SVR) 800-1200 dynes/sec/cm³

Various sources of CGRP may be used in the methods of this invention.For example, synthetic CGRP may be obtained using an automatic peptidesynthesizer according to well known methods. One method for synthesizingthe CGRP is the well known Merrifield method (see, Merrifield, R. B., J.Am. Chem. Soc. 85:2149 (1963) and Merrifield, R. B., Science, 232:341(1986), which are specifically incorporated herein by reference). HumanCGRP also may be obtained from commercial sources, such as PeninsulaLaboratory (Belmont, Calif.), Bachem Biosciences, Inc. (King of Prussia,Pa.) and Sigma Chemicals (St. Louis, Mo.). Commercial grade human CGRPis not marketed for human use (since this grade is not GMP/GLP grade);therefore, commercially available human CGRP may be used in the presentinvention only if it is purified and sterilized so that it is fit forhuman use. Genetically engineered human CGRP can also be used in thepresent invention. Similar results also could be achieved using a CGRPanalogue or an analogue based on the CGRP “receptor structure.” Theseinclude peptide-based analogues, as well as peptide-mimetic analogues.Accordingly, analogs that function similarly to CGRP are considered tobe equivalents of CGRP for purposes of this invention. Animal-derivedCGRP is biologically active and thus could be used in the presentinvention; however, as a practical matter, animal-derived CGRP presentsallergy and autoimmune problems and therefore is preferably avoided.

Other forms of CGRP that are suitable for use in the methods of thisinvention are pharmaceutically acceptable prodrugs of CGRP. A“pharmaceutically acceptable prodrug” is a compound that may beconverted under physiological conditions or by solvolysis to thespecified compound or to a pharmaceutically acceptable salt of suchcompound. Prodrugs of CGRP may be identified using routine techniquesknown in the art. Prodrugs include compounds wherein an amino acidresidue, or a polypeptide chain of two or more (e.g., two, three orfour) amino acid residues is covalently joined through an amide or esterbond to a free amino, hydroxy or carboxylic acid group of compounds ofthe present invention. Additional types of prodrugs are alsoencompassed. For instance, free carboxyl groups can be derivatized asamides or alkyl esters. Free hydroxy groups may be derivatized usinggroups including but not limited to hemisuccinates, phosphate esters,dimethylaminoacetates, and phosphoryloxymethyloxycarbonyls, as outlinedin Advanced Drug Delivery Reviews 1996, 19, 115. Carbamate prodrugs ofhydroxy and amino groups are also included, as are carbonate prodrugs,sulfonate esters and sulfate esters of hydroxy groups. Derivatization ofhydroxy groups as (acyloxy)methyl and (acyloxy)ethyl ethers wherein theacyl group may be an alkyl ester, optionally substituted with groupsincluding but not limited to ether, amine and carboxylic acidfunctionalities, or where the acyl group is an amino acid ester asdescribed above, are also encompassed. Prodrugs of this type aredescribed in J. Med. Chem. 1996, 39, 10. Free amines can also bederivatized as amides, sulfonamides or phosphonamides. All of theseprodrug moieties may incorporate groups including but not limited toether, amine and carboxylic acid functionalities. Other examples of suchprodrug derivatives are described in a) Design of Prodrugs, edited by H.Bundgaard, (Elsevier, 1985) and Methods in Enzymology, Vol. 42, p.309-396, edited by K. Widder, et al. (Academic Press, 1985); b) ATextbook of Drug Design and Development, edited by Krogsgaard-Larsen andH. Bundgaard, Chapter 5 “Design and Application of Prodrugs”, by H.Bundgaard p. 113-191 (1991); c) H. Bundgaard, Advanced Drug DeliveryReviews, 8:1-38 (1992); d) H. Bundgaard, et al., J. PharmaceuticalSciences, 77:285 (1988); and e) N. Kakeya, et al., Chem. Pharm. Bull.,32:692 (1984), each of which is specifically incorporated herein byreference.

When administered in controlled dosages, CGRP has pronouncedcardiovascular benefits, including vasodilation, ischemiccardioprotection, reduction in infarction size due to heart attack,inhibition of platelet aggregation and smooth muscle cell proliferationto potentially reduce the incidence of restenosis, increased renalfunction, and overall increased efficiency of cardiovascular functions.CGRP also plays a role in regulating inotropy, chronotropy,microvascular permeability, vascular tone, and angiogenesis.

As stated, CGRP has significant advantages over conventional drugtreatments. First, CGRP does not produce the potentially dangerous sideeffects, toxicity and tolerance associated with conventionalcardiovascular drugs such as nitroglycerin, Dobutamine and Natrecor. Infact, CGRP has been reported to down-regulate immune response viainhibition of cytokine release and has been safely administered toimmunosuppressed subjects without the induction of sensitivity. Second,since CGRP possesses multiple hemodynamic benefits, it potentiallyreduces or eliminates the need for drug cocktails to maintain specifichemodynamic functions. Third, more than 20 years of research on thepotency, safety and efficacy of the drug in animals and humans havedemonstrated the cardiovascular benefits of CGRP and have shown thatCGRP exhibits virtually no side effects or tolerance when administeredsystemically.

In general, there are four goals in treating HF patients: (1) treatingthe symptoms, (2) slowing the progression of cardiac dysfunction, (3)decreasing length of hospital stay, and (4) increasing the time betweenhospitalization, all while minimizing health care costs. It is believedthat the methods for the treatment or prophylaxis of HF according tothis invention will achieve one or more of these goals.

In order to use CGRP for the therapeutic treatment (includingprophylactic treatment) of mammals including humans according to themethods of this invention, it is normally formulated in accordance withstandard pharmaceutical practice as a pharmaceutical composition.According to this aspect of the invention there is provided apharmaceutical composition comprising CGRP in association with apharmaceutically acceptable diluent or carrier, wherein the CGRP ispresent in an amount for effective treating or preventing HF and/or forimproving renal function.

CGRP can be administered to a patient by any available and effectivedelivery system including, but not limited to, parenteral, transdermal,intranasal, sublingual, transmucosal, intra-arterial, or intradermalmodes of administration in dosage unit formulations containingconventional nontoxic pharmaceutically acceptable carriers, adjuvants,and vehicles as desired, such as a depot or a controlled releaseformulation.

For example, CGRP or a pharmaceutically acceptable formulation thereofmay be formulated for parenteral administration, e.g., for intravenous,subcutaneous, or intramuscular injection. For an injectable formulation,a dose of CGRP may be combined with a sterile aqueous solution which ispreferably isotonic with the blood of the patient. Such a formulationmay be prepared by dissolving a solid active ingredient in watercontaining physiologically-compatible substances such as sodiumchloride, glycine, and the like, and having a buffered pH compatiblewith physiological conditions so as to produce an aqueous solution, andthen rendering the solution sterile by methods known in the art. Theformulations may be present in unit or multi-dose containers, such assealed ampules or vials. The formulation may be delivered by any mode ofinjection, including, without limitation, epifascial, intracutaneous,intramuscular, intravascular, intravenous, parenchymatous, subcutaneous,oral or nasal preparations (see, for example, U.S. Pat. No. 5,958,877,which is specifically incorporated herein by reference).

Pharmaceutical compositions may also be in the form of a sterileinjectable aqueous or oily suspension, which may be formulated accordingto known procedures using one or more appropriate dispersing or wettingagents and suspending agents. A sterile injectable preparation may alsobe a sterile injectable solution or suspension in a non-toxicparenterally-acceptable diluent or solvent, for example a solution in1,3-butanediol.

In any of the embodiments of this invention, CGRP is optionallyconjugated to a biocompatible, biodegradable polymer to form aconjugate. As used herein, the term-“conjugate” refers to a CGRPmolecule covalently or noncovalently coupled to one or more polymers.Examples of polymers include, but are not limited to, biologicalpolymers (e.g., polysaccharides, polyamides, pharmacologically inertnucleotide components, etc.), derivatives of biological polymers, andnon-biological polymers. Specific examples include, but are not limitedto, poly(alkylene glycols such as poly(ethylene glycol) (PEG),poly-lactic acid (PLA), poly-glycolic acid, poly(ε-caprolactone),poly(β-hydroxybutyrate), poly(β-hydroxyvalerate), polydioxanone,poly(malic acid), poly(tartronic acid), poly(ortho esters),polyanhydrides, polycyanoacrylates, poly(phosphoesters),polyphosphazenes, hyaluronidate, polysulfones, polyacrylamides,polymethacrylate, chimeric recombinant elastin-silk protein (ProteinPolymers, Inc.) and collagen (Matrix Pharmaceuticals, Inc) (for detaileddiscussion of the above mentioned polymers, see, Park, K. et al. (1993)Biodegradable Hydrogels for Drug Delivery. Technomic Publishing Co.,Inc., Lancaster, Pa.). The polymers noted above can optionally becrosslinked to modify the utility thereof, such as to render thecompounds more or less water soluble. Numerous crosslinking agents areuseful, including diols and higher polyols, polyamines, polycarboxylicacids, polyisocyanates and the like.

CGRP can be conjugated to any of the above-described polymers usingconventional methods known to those skilled in the art, wherein theconjugation is performed under conditions which do not substantiallyreduce the pharmacological activity of CGRP. For example, CGRP can becovalently coupled to the polymer directly through reaction of areactive group on the CGRP with a reactive group of the polymer. Theterm “reactive group” refers to a chemical moiety which is attached toCGRP or the polymer or bonds in the polymer which participate in thechemical reaction between the components involved, i.e., CGRP and thepolymer. Examples of reactive groups include without limitationhydroxyl, carboxyl, amine, amid; carbon-carbon double and triple bonds,epoxy groups, halogen or other leaving groups and the like.Alternatively, CGRP can be coupled to the polymer through a linkinggroup. The term “linking group” is not limited to molecules per se, andrefers to compounds, molecules and molecular fragments that can reactwith the polymer, monomers and CGRP to attach CGRP to the polymer. Assuch, the linking groups include compounds and the like with more thanone reactive group, preferably two or three reactive groups.

Parenteral Administration

According to one embodiment, this invention provides a method oftreating HF in a patient comprising administering CGRP or apharmaceutically acceptable composition thereof to the patient at a ratebetween about 50 and 500 ng/min for a time between 30 minutes and 8hours per day for as many days as needed to provide symptomatic relief,prevent exacerbation of symptoms, and/or prevent and/or delayprogression of the disease state of heart failure in said patient. Forexample, CGRP may be continuously or intermittently administered for aperiod of time between about 24 and 48 hours, or as a bolus dose. IfCGRP is administered two or more times intermittently each day, lowerdoses, e.g., 0.8 to 10 ng/min can be administered.

Treatment is continued as needed to provide symptomatic relief, preventexacerbation of symptoms, and/or prevent and/or delay progression of thedisease state of heart failure in said patient, or until it is no longerwell tolerated by the patient, or until a physician terminatestreatment. For example, a physician may monitor one or more symptoms ofHF, renal blood flow, glomerular filtration rates, and/or serum levelsof urea and creatinine in a patient being treated with CGRP according tothis invention and, upon observing attenuation of one or more symptomsof HF for a period of time, conclude that the patient can sustain thepositive effects of the above-described treatment without furtheradministration of CGRP for a period of time. If necessary, the patientmay then return at a later point in time for additional treatment asneeded.

According to another embodiment, this invention provides a method oftreating HF in a patient comprising administering CGRP to the patient ata rate between about 500 and 600 ng/min for period between about 8 hoursper day for at least three consecutive days or several times per week asneeded to provide symptomatic relief, prevent exacerbation of symptoms,and/or prevent and/or delay progression of the disease state of heartfailure in the patient. This treatment may be provided as outpatienttherapy to prevent exacerbation of the heart failure and to enhance thequality of life in the patient.

As used herein, “day” means a 24-hour period. Thus, for example, “for atleast three consecutive days” means for at least a 72-hour period.During or after the treatment, a physician may monitor one or moresymptoms of HF, renal blood flow, glomerular filtration rates, and/orserum levels of urea or creatinine in the patient and, upon observing animprovement in one or more of the parameters for a period of time,conclude that the patient can sustain the positive effects of thetreatment without further administration of CGRP for a period of time.

According to another embodiment, this invention provides a method oftreating HF in a patient comprising administering CGRP to the patient ata rate between about 50 and 400 ng/min over a period of up to 8 hoursper day for each day of hospitalization of the patient or as needed. Incertain cases the patient may require higher doses, for example up to 2μg/min over the same time period.

Once treatment with CGRP according to any of the methods of thisinvention has achieved the desired results, e.g., symptomatic relief,prevent exacerbation of symptoms, and/or prevent and/or delayprogression of the disease state of heart failure, the patient can thenreceive maintenance therapy if desired. For example, a lower dose ofCGRP, e.g., less than 10 ng/min, can be administered to the patient formaintenance therapy by any suitable route including, but not limited to,injection, intravenous administration, etc. In one embodiment, thedelivery regime can be designed to deliver between CGRP at a ratebetween about 0.8 to 10 ng/min for a desired period of time, such asover a period of 3, 6 or 9 months.

Because CGRP therapy according to any of the methods of this inventionprevents further damage from ischemic injury and promotes the healingprocess, it can also be used to delay or preclude further exacerbationof a heart condition into a more serious and progressive diseases suchas HF. Thus, each of the above-described methods may also be used as aprophylactic treatment to prevent or slow the progression of earlystages of HF to more advanced stages. That is, once treatment with CGRPaccording to any of the methods of this invention has achieved thedesired results, the patient can optionally receive maintenance therapythereafter. For example, one embodiment of this invention for providingmaintenance therapy to a patient with a heart condition comprisesproviding a lower dose of CGRP, e.g., less than 10 ng/min, to thepatient for maintenance therapy by any suitable route including, but notlimited to, injection, intravenous administration, controlled releaseadministration, etc. In one embodiment, the delivery system can bedesigned to deliver between CGRP at a rate between about 0.8 to 10ng/min for a desired period of time, such as over a period of 3, 6 or 9months. In an alternative embodiment, the patient can receive long-term,low dose, maintenance administration of CGRP from a controlled releaseformulation.

In addition, it is known that a patient that has suffered a myocardialinfarction (MI) will likely suffer another MI in the future. Thus, apatient having an MI can be treated with an initial dose of CGRPaccording to any of the methods of this invention until one or moresymptoms of HF has diminished, and subsequently can be put on a CGRPmaintenance dosing regime. The maintenance regime can also be given to apost-MI patient that was initially treated for MI by means other thanCGRP, and can also be used for HF patients that have not yet suffered anMI as a means to slow the progression of HF into the more advancedstages or to prevent or reduce the risk of MI in patients with advancedHF.

This invention further provides methods for improving renal function ina patient suffering from diminished renal function comprisingadministering CGRP according to any of the above-describe dosing regimesfor treating HF. As used herein, the term “improved renal function”includes increased glomerular filtration, increased renal blood flow anddecreased serum levels of urea and creatinine.

If necessary, CGRP can be administered according to the methods of thisinvention either alone or in combination with at least one other agentincluding, but not limited to, anti-proliferative agents, anti-clottingagents, vasodilators, diuretics, beta-blockers, calcium ion channelblockers, blood thinners, cardiotonics, ACE inhibitors,anti-inflammatories, antioxidants, and/or gene therapeutics. When usedin combination with other agents, CGRP and the agent can be administeredseparately (either simultaneously or separately in any order) or inadmixture. In one embodiment, when CGRP and at least one other agent areadministered as separate components, they are administered to thepatient at about the same time. “About the same time” means that withinabout thirty minutes of administering one compound (e.g., CGRP) to thepatient, the other compound (e.g., an anti-proliferative oranti-clotting agent) is administered to the patient. “About the sametime” also includes concomitant or simultaneous administration of thecompounds.

Controlled Release Administration

Another aspect of this invention provides methods of treating HF and/orrenal failure by delivering CGRP to a patient as a controlled releasesformulation. As used herein, the term “controlled” or “sustained”release of CGRP includes continuous or discontinuous, linear ornon-linear release of CGRP. There are many advantages for a controlledrelease formulation of CGRP. Among these are the convenience of a singleinjection for the patient, avoidance of peaks and valleys in systemicCGRP concentration which can be associated with repeated injections, thepotential to reduce the overall dosage of CGRP, delayed progression ofHF, cardioprotection, and the potential to enhance the pharmacologicaleffects of CGRP. A lower, sustained dose can also prevent adverseaffects that are occasionally observed with infusion therapy. Inaddition to significantly reducing the cost of care, controlled releasedrug therapy can free the patient from repeated treatment orhospitalization, thus offering the patient greater flexibility andimproving patient compliance. A controlled release formulation of CGRPalso provides an opportunity to use CGRP in a manner not previouslyexploited or considered, such as a maintenance therapeutic for patientsthat have suffered an MI or in patients at high risk of suffering an MI,such as Stage B, C and D heart failure patients.

1. Controlled Release Implant

One embodiment of a controlled release composition of this inventioncomprises suitable for use in treating or preventing HF comprises aflowable composition that forms a biodegradable implant comprising CGRPin situ. This invention further comprises a kit that includes theflowable composition. The flowable composition comprises abiodegradable, biocompatible thermoplastic polymer or copolymer incombination with a suitable polar solvent and CGRP. The thermoplasticpolymers or copolymers are substantially insoluble in water and bodyfluid and are biodegradable and/or bioerodible within the body of ananimal. The flowable composition is administered for example as a liquidor gel to a tissue or bodily fluid wherein the implant (i.e., a polymermatrix) is formed in situ, and CGRP is subsequently released from thematrix by diffusion or dissolution from within the polymer matrix and/orby the degradation of the polymeric matrix. The composition isbiocompatible and the polymer matrix does not cause substantial tissueirritation or necrosis at the implant site. Examples of biocompatible,biodegradable controlled release polymer formulations suitable forpurposes of this invention are provided in U.S. Pat. Nos. RE 37,950 E,6,143,314 and 6,582,080 B2, which are specifically incorporated hereinby reference.

More specifically, a flowable thermoplastic polymeric composition ofthis invention comprises a thermoplastic polymer or copolymer dissolvedin a pharmaceutically-acceptable organic solvent that is miscible todispersible in an aqueous medium to provide a polymeric solution, andCGRP or a CGRP conjugate either dissolved to form a homogeneous solutionor dispersed to form a suspension or a dispersion of CGRP within thepolymeric solution. When the polymer solution is placed in an aqueousenvironment, such as a bodily tissue or fluid which typically surroundtissues or organs in an organism, the organic solvent dissipates ordisperses into the aqueous or body fluid. Concurrently, the polymerprecipitates or coagulates to form a solid matrix or implant and CGRPbecomes trapped or encapsulated within the polymeric matrix as theimplant solidifies. Once the solid implant is formed, CGRP is releasedfrom the solid matrix by diffusion or dissolution from within thepolymeric matrix and/or by the degradation of the polymeric matrix.

Preferably, the flowable composition is a liquid, gel, paste or puttysuitable for injection in a patient. As used herein, “flowable” refersto the ability of the composition to be administered by any suitablemeans into the body of a patient. For example, the composition can beinjected into a specific site in the patient with the use of a syringeand puncture needle or placed into accessible tissue sites through acannula. The ability of the composition to be injected into a patientwill typically depend upon the viscosity of the composition. Thecomposition will therefore have a suitable viscosity such that thecomposition can be forced through the medium (e.g., syringe) into thebody of a patient. As used herein, a “liquid” is a substance thatundergoes continuous deformation under a shearing stress (ConciseChemical and Technical Dictionary, 4^(th) Enlarged Ed., ChemicalPublishing Co., Inc., p. 707, N.Y., NY (1986)). The term “gel” refers asubstance having a gelatinous, jelly-like, or colloidal property(Concise Chemical and Technical Dictionary, 4^(th) Enlarged Ed.,Chemical Publishing Co., Inc., p. 567, N.Y., NY (1986)).

The term “biodegradable” means that the polymer matrix will degrade overtime, for example by the action of enzymes, by hydrolytic action and/orby other similar mechanisms in the patient's body. By “bioerodible,” itis meant that the polymer matrix will erode or degrade over time due, atleast in part, to contact with substances found in the surroundingtissue fluids or cellular action. By “bioabsorbable” it is meant thatthe polymer matrix will be broken down and absorbed within the humanbody, for example, by a cell or tissue. “Biocompatible” means that thepolymer, the solvent and the resulting polymer matrix will not elicit anadverse biologic response in the patient.

A thermoplastic composition is provided in which a biodegradable polymerand CGRP are dissolved in a biocompatible solvent to form a flowablecomposition, which can then be administered, for example, via a syringeand puncture needle or a catheter. Any suitable biodegradable,bioabsorbable, and/or bioerodible thermoplastic polymer can be employed,provided the biodegradable thermoplastic polymer is at leastsubstantially insoluble in aqueous medium or body fluid. Suitablebiodegradable thermoplastic polymers are disclosed, e.g., in U.S. Pat.Nos. 5,324,519; 4,938,763; 5,702,716; 5,744,153; and 5,990,194, each ofwhich is specifically incorporated herein by reference. Thethermoplastic polymers can be made form a variety of monomers which formlinear or branched polymer chains or monomeric units joined together bylinking groups such as esters, amides, urethanes, etc. According to oneembodiment, some fraction of one of these starting monomers will be atleast trifunctional, and provides at lest some branching of theresulting polymer chain. Examples of suitable biodegradable polymersinclude, but are not limited to, polylactides, polyglycolides,polycaprolactones, polyanhydrides, polyamides, polyorthoesters,polyurethanes, polyesteramides, polydioxanones, polyacetals, polyketals,polycarbonates, polyorthocarbonates, polyphosphazenes,polyhydroxybutyrates, polyhydroxyvalerates, polyalkylene oxalates,polyacrylates, polyalkylene succinates, poly(malic acid), poly(aminoacids) and copolymers, terpolymers, cellulose diacetate and ethylenevinyl alcohol copolymers, and combinations thereof.

The type, molecular weight, and amount of biodegradable thermoplasticpolymer present in the composition will typically depend upon thedesired properties of the controlled release implant. For example, thetype, molecular weight, and amount of biodegradable thermoplasticpolymer can influence the length of time in which CGRP is released fromthe controlled release implant. Specifically, in one embodiment of thepresent invention, the composition can be used to formulate a one monthdelivery system of CGRP. In such an embodiment, the biodegradablethermoplastic polymer can preferably be 50/50poly(DL-lactide-co-glycolide), can be present in about 30 wt. % to about40 wt. % of the composition, and can have an average molecular weight ofabout 12,000 to about 45,000. Alternatively, in another embodiment thecomposition can be used to formulate a three month delivery system ofCGRP. In such an embodiment, the biodegradable thermoplastic polyestercan preferably be 75/25 poly(DL-lactide-co-glycolide), can be present inabout 40 wt. % to about 50 wt. % of the composition, and can have anaverage molecular weight of about 15,000 to about 24,000.

The molecular weight of the polymer used in the present invention canaffect the rate of CGRP release in situ from the implant. As themolecular weight of the polymer increases, the rate of CGRP release fromthe system decreases. This phenomenon can be advantageously used in theformulation of systems for the controlled release of CGRP. Forrelatively quick release of CGRP, low molecular weight polymers can bechosen to provide the desired release rate. For release of a CGRP over arelatively long period of time, a higher polymer molecular weight can bechosen. Accordingly, a polymer system can be produced with an optimumpolymer molecular weight range for the release of CGRP over a selectedlength of time. The molecular weight of a polymer can be varied by anyof a variety of methods known to persons skilled in the art.

The particular biocompatible polymer employed is not critical and isselected relative to the viscosity of the resulting polymer solution,the solubility of the biocompatible polymer in the biocompatiblesolvent, the desired release rate, and the like. Such factors are wellknown to persons skilled in the art. The biodegradable thermoplasticpolyester is preferably present in about 30 wt. % to about 50 wt. % ofthe flowable composition. Preferably, the biodegradable thermoplasticpolyester has an average molecular weight of about 12,000 to about45,000 and more preferably from about 15,000 to about 30,000.

The concentration of the polymer dissolved in the various solvents willdiffer depending upon the type of polymer and its molecular weight, andthese factors can be varied to obtain optimum injection efficiency. CGRPis added to the polymer solution where it is either dissolved to form ahomogenous solution or dispersed to form a suspension or a dispersion ofdrug within the polymeric solution.

Suitable organic solvents for preparing the thermoplastic polymercomposition are those that are biocompatible, pharmaceuticallyacceptable, and able to diffuse into in aqueous or body fluids so thatthe flowable composition coagulates or solidifies. The organic solventis capable of diffusing, dispersing, or leaching from the composition insitu into aqueous tissue or body fluid of the implant site. Examples ofsuitable solvents include substituted heterocyclic compounds such asN-methyl-2-pyrrolidone and 2 pyrrolidone; esters of carbonic acid andalkyl alcohols such as propylene carbonate, ethylene carbonate anddimethyl carbonate; alkyl esters of mono-, di-, and tricarboxylic acidssuch as 2-ethyoxyethyl acetate, ethyl acetate, methyl acetate, ethyllactate, ethyl butyrate, diethyl malonate, diethyl glutonate, tributylcitrate, diethyl succinate, tributyrin, isopropyl myristate, dimethyladipate, dimethyl succinate, dimethyl oxalate, dimethyl citrate,triethyl citrate, acetyl tributyl citrate, glyceryl triacetate; alkylketones such as acetone and methyl ethyl ketone; alcohols such assolketal, glycerol formal, and glycofurol; dialkylamides such asdimethylformamide, dimethylacetamide; dimethylsulfoxide (DMSO) anddimethylsulfone; tetrahydrofuran; lactones such as ε-caprolactone andbutyrolactone; cyclic alkyl amides such as caprolactam; aromatic amidessuch as N,N-dimethyl-m-toluamide and 1-dodecylazacycloheptan-2-one; andmixtures and combinations thereof. Preferred solvents include polaraprotic solvents such as N-methyl-2-pyrrolidone, 2-pyrrolidone,N-dimethyl formamide, dimethylsulfoxide, caprolactam, triacetin, ethyllactate, propylene carbonate, solketal, glycerol formal, glycofurol, orany combination thereof.

The solvent can be present in any suitable amount, provided the solventis miscible to dispersible in aqueous medium or body fluid. The type andamount of biocompatible solvent present in the composition willtypically depend upon the desired properties of the controlled releaseimplant. For example, the type and amount of biocompatible solvent caninfluence the length of time in which the CGRP is released from thecontrolled release polymer matrix. Preferably, the solvent is present inabout 45-70 wt. % of the polymeric composition. Specifically, in oneembodiment of the present invention, the composition can be used toformulate a one month delivery system of CGRP. In such an embodiment,the biocompatible solvent can preferably be N-methyl-2-pyrrolidone andcan preferably present in about 60 wt. % to about 70 wt. % of thecomposition. Alternatively, in another embodiment of the presentinvention, the composition can be used to formulate a three monthdelivery system of CGRP. In such an embodiment, the biocompatiblesolvent can preferably be N-methyl-2-pyrrolidone and can preferablypresent in about 50 wt. % to about 60 wt. % of the composition.

The solubility of the biodegradable thermoplastic polymers in thevarious solvents will differ depending upon their crystallinity, theirhydrophilicity, hydrogen-bonding, and molecular weight. Thus, not all ofthe biodegradable thermoplastic polymers will be soluble in the samesolvent, and each biodegradable thermoplastic polymer or copolymer willhave its appropriate solvent.

A method for forming a flowable polymeric composition includes mixing,in any order, a biodegradable thermoplastic polyester, a biocompatiblesolvent, and CGRP. These ingredients, their properties, and preferredamounts are as disclosed above. The mixing is performed for a sufficientperiod of time effective to form the flowable composition for use as acontrolled release implant. Preferably, the biocompatible thermoplasticpolyester and the biocompatible solvent are mixed together to form amixture and the mixture is then combined with CGRP to form the flowablecomposition. If necessary, gentle heating and stirring can be used toeffect dissolution of the biocompatible polymer into the biocompatiblesolvent.

The amount of CGRP incorporated into the polymeric composition dependsupon several factors, including but not limited to the desired releaseprofile, the concentration of CGRP required for a biological effect, andthe length of time that CGRP has to be released for effective treatment.There is no critical upper limit on the amount of CGRP incorporated intothe polymer solution except for that of an acceptable solution ordispersion viscosity for injection through a syringe needle. The lowerlimit of CGRP incorporated into the delivery system is dependent simplyupon the activity of the CGRP and the length of time needed fortreatment.

The release of CGRP from the solid polymer matrices (implants) willfollow the same general rules for release of a drug from a monolithicpolymeric device. The release of CGRP can be affected by the size of theimplant (i.e., the amount of polymer composition administered to thepatient), the loading of CGRP within the implant, the permeabilityfactors involving CGRP and the particular polymer, and the degradationof the polymer. Depending upon the amount of CGRP selected for delivery,the above parameters can be adjusted by one skilled in the art of drugdelivery to give the desired rate and duration of release. Thus, theflowable composition can be designed to produce an implant that willrelease CGRP over a targeted period from days to months.

The amount of flowable composition administered will typically dependupon the desired properties of the controlled release implant. Forexample, the amount of flowable composition can influence the length oftime in which CGRP is released from the controlled release implant.

It is desirable with any of the controlled release systems orformulations described herein that CGRP is delivered to the patient at arate and in an amount that will achieve blood plasma levels necessary toprovide symptomatic relief, e.g., by attenuating one or more symptoms ofHF. The following are examples of minimum and maximum IV infusion rates,cumulative daily dose and plasma levels required to bring about the fullrange of hemodynamic benefits that CGRP induces without any serious sideeffects in hemodynamically compromised patients. Minimal and transientfacial flushing may be observed, but dosages are very well tolerated inIV infusions.

1. Minimum infusion rate and daily dose delivered to cause attenuationof one or more symptoms of HF for a patient weighing 70 kg: 0.0008μg/kg/min× 70 kg×1440 minutes=80.64 μg/day.

2. Maximum infusion rate and daily dose delivered to cause attenuationof one or more symptoms of HF for a patient weighing 70 kg: 0.016μg/kg/min× 70 kg×1440 minutes=1.6 mg/day.

It is well within the skill of persons skilled in the art to determinethe amount of CGRP to be loaded into a particular drug delivery systemto provide the desired steady state plasma levels of CGRP as describedherein to provide relief of one or more symptoms of HF or to improve oneor more hemodynamic properties according to the methods of thisinvention.

The following is an example of the amount of CGRP to include in atransdermal delivery system that will deliver CGRP across the skin at arate suitable to maintain a steady state plasma level of 157±26 pg/mL,which has been found to produce profoundly beneficial hemodynamicresponses including increased cardiac output, decreased ventricularfilling pressures, pulmonary and systemic arterial pressures, vascularresistance, increased glomerular filtration, and renal blood flow. If itis assumed that a transdermal delivery system can deliver 25% of theloaded CGRP across the skin, then in order to deliver a total drug loadsimilar to that delivered by an IV dose of 560 ng/min (0.008 μg/kg/min)over 8-24 hours (i.e., delivery of 288-806 μg CGRP) the total drug loadrequired for the transdermal delivery system would be approximately1.152-3.456 mg. Polymer matrix systems capable of delivering 100% of thedrug at a rate suitable to maintain similar steady state plasma levelswould require a total drug load four times less than transdermalsystems, i.e., 0.288-0.806 mg. Peak plasma levels of CGRP at 157±26pg/ml are obtained in the first 60 minutes. In a preferred embodimentthe peak level is maintained for 8-24 hours.

Tables 2 and 3 show examples of the amount of CGRP to be added to aflowable composition and the corresponding injection volumes in order toproduce implants that will provide the indicated delivery rates over 7,30, 60, 90, 120 or 180 days and maintain steady state plasma levels ofCGRP up to 157±26 pg/mL. In Tables 2 and 3, delivery rates and CGRPloads are provided for compositions that will produce implants in situcomprising 5 wt. % and 15 wt. % CGRP, respectively.

TABLE 2 Thermoplastic polymer compositions comprising 5% CGRP Durationof release (Days) Delivery Rate 7 30 90 120 180 0.0008 μg/kg/min DrugLoad (mg) 0.56 2.42 7.26 9.68 14.52 Injection (cc) 0.01 0.05 0.15 0.190.29 0.0032 μg/kg/min Drug Load (mg) 2.26 9.69 29.07 38.76 58.14Injection (cc) 0.04 0.19 0.58 0.77 1.16  0.008 μg/kg/min Drug Load (mg)5.64 24.18 72.54 96.72 145.08 Injection (cc) 0.11 0.48 1.45 1.93 2.90 0.016 μg/kg/min Drug Load (mg) 11.27 48.30 144.90 193.20 289.80Injection (cc) 0.22 0.97 2.90 3.86 5.80

TABLE 3 Thermoplastic polymer compositions comprising 15% CGRP Durationof release (Days) Delivery Rate 7 30 90 120 180 0.0008 μg/kg/min DrugLoad (mg) 0.56 2.42 7.26 9.68 14.52 Injection (cc) 0.004 0.02 0.05 0.0650.097 0.0032 μg/kg/min Drug Load (mg) 2.26 9.69 29.07 38.76 58.14Injection (cc) 0.02 0.07 0.19 0.26 0.39  0.008 μg/kg/min Drug Load (mg)5.64 24.18 72.54 96.72 145.08 Injection (cc) 0.04 0.16 0.48 0.64 0.97 0.016 μg/kg/min Drug Load (mg) 11.27 48.30 144.90 193.20 289.80Injection (cc) 0.08 0.32 0.97 1.29 1.93

For example, in one embodiment of the present invention, a polymericcomposition comprising 5 wt. % CGRP (i.e., 5.64 mg CGRP) can beformulated to produce a polymer matrix in situ that will deliver CGRP atcirculating plasma levels of CGRP up to 157±26 pg/mL or deliver CGRP ata rate of 0.008 μg/kg/min over a period of 7 days when about 0.11 mL ofthis composition is administered to a patient (Table 2). Alternatively,if it is desired to have the CGRP delivered at circulating plasma levelsof CGRP of 157±26 pg/mL or a rate of 0.008 μg/kg/min over a period of180 days, a composition comprising 15 wt. % CGRP (i.e., 145.08 mg CGRP)can be prepared and about 0.97 mL of this composition is administered tothe patient (Table 3). In a similar fashion, other compositions can beprepared according to the examples shown in Tables 2 and 3 to providethe desired circulating plasma levels of CGRP and delivery rate over thetargeted time period. It is to be understood that the formulations inTables 2 and 3 are provide as examples to illustrate the invention, andit would be well within the skill of persons of ordinary skill in theart to design other formulations that would yield different deliveryrates over different time periods.

The compositions of this invention can be delivered directly to a targetsite and can be designed to provide continuous release of CGRP over atargeted time period so as to reduce the frequency of drugadministration. In general, a solid implant or matrix is formed upondispensing the flowable polymeric composition either into a tissue oronto the surface of a tissue which is surrounded by an aqueous medium.The composition can be delivered to a patient's tissue or bodily fluidby any convenient technique. For example, the thermoplastic polymericsolution can be placed in a syringe and injected through a needle into apatient's body, i.e., in the desired tissue site or bodily fluid. Upondischarge of the composition from the needle into the tissue or fluid,the solvent dissipates or diffuses away from the polymer and into thesurrounding fluid, resulting in the precipitation of the biocompatiblepolymer which precipitate forms a coherent mass or polymer matrix. Thepolymer matrix can adhere to its surrounding tissue or bone bymechanical forces and can assume the shape of its surrounding cavity andconform to the irregular surface of the tissue. The implant willbiograde over time and does not require removal when CGRP is depleted.

In certain instances, formation of the solid matrix from the flowabledelivery system is not instantaneous. For example, the process can occurover a period of minutes to several hours. During this period, the rateof diffusion of CGRP from the coagulating polymeric composition may bemuch more rapid than the rate of release that occurs from thesubsequently formed solid matrix. “Initial burst” refers to the releaseof a CGRP from the polymeric composition during the first 24 hours afterthe polymeric composition is contacted with an aqueous fluid. Thisinitial “burst” of CGRP that is released during polymer matrix formationmay result in the loss or release of a large amount of the active agent.Therefore, in certain embodiments the thermoplastic polymer compositioncan further comprise a polymeric controlled release additive thatsubstantially reduces the “initial burst” of CGRP released from thepolymeric composition during the initial 24 hours after implantation.The use of such an additive is described in U.S. Pat. No. 6,143,314,which is specifically incorporated herein by reference. As used herein,the term “substantially reduces” means a decrease of at least 15%, andpreferably between about 15% to about 70%, of CGRP that is released fromthe polymeric composition compared to a composition without theadditive. Examples of suitable controlled release additives includethermoplastic polymers having poly(lactide-co-glycolide) (PLG) moietiesand polyethylene glycol (PEG) moieties. In one embodiment, thecontrolled release additive is a poly(lactide-co-glycolide)/polyethyleneglycol (PLG/PEG) block copolymer. The polymeric controlled releaseadditive is present in the polymeric composition in an amount effectiveto reduce the initial burst of biologically active agent released fromthe polymeric composition during the first 24 hours after implantation.Preferably, the polymeric composition includes about 1 wt. % to about 50wt. %, more preferably about 2 wt. % to about 20 wt. % of the polymericcontrolled release additive.

The solid matrix is capable of biodegradation, bioerosion and/orbioabsorption within the implant site of the patient or animal, and willslowly biodegrade within the body and will release CGRP contained withinits matrix at a controlled rate until depleted. Generally, the polymermatrix will breakdown over a period from about 1 week to about 12months. The release of CGRP can be affected by the size and shape of thepolymer matrix, the loading of drug within the polymer matrix, thepermeability factors involving CGRP and the particular polymer, and thedegradation of the polymer. The above parameters can be adjusted by oneskilled in the art of drug delivery to give the desired rate andduration of release (see for example Tables 2 and 3).

The polymeric CGRP solution can be placed anywhere within the body,including tissue sites such as soft tissue (e.g., muscle or fat), hardtissue (e.g., bone), or a cavity such as the periodontal, oral, vaginal,rectal, or nasal cavity. As used herein, the term “tissue site” includesany tissues in an organism. A tissue site is typically surrounded by anaqueous or body fluid such as subcutaneous tissue, interstitial fluid,blood, serum, cerebrospinal fluid or peritoneal fluid.

A suitable polymeric gel for use in this embodiment comprises ABA-orBAB-type block copolymers, where the A-blocks are relatively hydrophobicA polymer blocks comprising a biodegradable polyester, and the B-blocksare relatively hydrophilic B polymer blocks comprising polyethyleneglycol (PEG). The A block is preferably a biodegradable polyestersynthesized from monomers selected from the group consisting ofD,L-lactide, D-lactide, L-lactide, D,L-lactic acid, D-lactic acid,L-lactic acid, glycolide, glycolic acid, ε-caprolactone,ε-hydroxyhexanoic λ-hydroxybutyric acid, δ-valerolactone,δ-hydroxyvaleric acid, hydroxybutyric acids, malic acid, and copolymersthereof, and the B block is PEG. The polymeric gel is preferablybiodegradable and exhibits water solubility at low temperatures andundergoes reversible thermal gelation at physiological mammalian bodytemperatures. Furthermore, these polymeric gels are biocompatible andcapable of releasing CGRP entrained within its matrix over time and in acontrolled manner. The polymeric gel may be prepared as disclosed inU.S. Pat. No. 6,201,072, which is incorporated herein by reference.

Other suitable polymers include in situ formed hydrogels prepared fromthermosensitive block copolymers. Such block copolymers undergoreversion between gel and sol under certain conditions. The gel-soltransition temperature is generally above room temperature, whichdepends on the composition of the gel, as well as on the chemicalstructure and molecular weight of PEG or PEG copolymers. The polymer isa poly(ethylene glycol), a derivative thereof, or a copolymer thatreacts with the poly(ethylene glycol) segment. The polymer can also bepoly(propylene glycol) (PPG) or other poly(alkylene glycols). Highermolecular weight poly(ethylene glycol) is also called poly(ethyleneoxide) (PEO). Poly(ethylene glycol) block copolymers with poly(propyleneoxide) (PPO), including an pluronic polymers (Poloxamers) may also beused. Different molecular weight of each segment, and weight ratio ofthe blocks, and different sequences may be used such as PEO-PPO-PEO(Pluronic), PPO-PEO-PPO (Pluronic-R), PEO-PPO, etc.

Suitable polymers useful in the invention include PLURONIC (BASF Corp.)surfactant which is a group of poly(ethylene oxide)-polypropyleneoxide)poly(ethylene oxide) triblock copolymers also known as poloxamers.The PEG block at both ends is able to complex with alpha-cyclodextrin,just like the PEG molecules. PLURONIC polymers have unique surfactantabilities and extremely low toxicity and immunogenic responses. Theseproducts have low acute oral and dermal toxicity and low potential forcausing irritation or sensitization, and the general chronic andsubchronic toxicity is low. In fact, PLURONIC polymers are among a smallnumber of surfactants that have been approved by the FDA for direct usein medical applications and as food additives (BASF (1990) Pluronic &Tetronic Surfactants, BASF Co., Mount Olive, N.J.). Recently, severalPLURONIC polymers have been found to enhance the therapeutic effect ofdrugs (March, K. L., et al., Hum. Gene Therapy 6 (1): 41-53, 1995).

The hydrogel-based injectable composition may be prepared in anysuitable manner. Generally, CGRP in aqueous solution is combined withthe poly(ethylene glycol) component. The mixture is cooled, generally toa temperature of 0° C. to 25° C. The resulting product is a whiteviscous hydrogel.

2. Films

This invention further provides a prophylaxis for or method of treatingHF and/or renal failure comprising administering biodegradable,biocompatible polymeric film comprising CGRP to a patient. The polymericfilms are thin compared to their length and breadth. The films typicallyhave a uniform selected thickness between about 60 micrometers and about5 mm. Films of between about 600 micrometers and 1 mm and between about1 mm and about 5 mm thick, as well as films between about 60 micrometersand about 1000 micrometers; and between about 60 and about 300micrometers are useful in the manufacture of therapeutic implants forinsertion into a patient's body. The films can be administered to thepatient in a manner similar to methods used in adhesion surgeries. Forexample, a CGRP film formulation can be sprayed or dropped onto a tissuesite during surgery, or a formed film can be placed over the selectedtissue site. In an alternative embodiment, the film can be used assustained release coating on a medical device such as a stent.

Either biodegradable or nonbiodegradable polymers may be used tofabricate implants in which the CGRP is uniformly distributed throughoutthe polymer matrix A number of suitable biodegradable polymers for usein making the biodegradable films of this invention are known to theart, including polyanhydrides and aliphatic polyesters, preferablypolylactic acid (PLA), polyglycolic acid (PGA) and mixtures andcopolymers thereof, more preferably 50:50 copolymers of PLA:PGA and mostpreferably 75:25 copolymers of PLA:PGA. Single enantiomers of PLA mayalso be used, preferably L-PLA, either alone or in combination with PGA.Polycarbonates, polyfumarates and caprolactones may also be used to makethe implants of this invention.

A plasticizer may be incorporated in the biodegradable film to make itsofter and more pliable for applications where direct contact with acontoured surface is desired.

The polymeric films of this invention can be formed and used as flatsheets, or can be formed into three-dimensional conformations or“shells” molded to fit the contours of the tissue site into which thefilm is inserted.

To make the polymeric films of this invention, a suitable polymericmaterial is selected, depending on the degradation time desired for thefilm. Selection of such polymeric materials is known to the art. A lowermolecular weight, e.g., around 20,000 daltons, 50:50 or 55:45 PLA:PGAcopolymer is used when a shorter degradation time is desired. To ensurea selected degradation time, the molecular weights and compositions maybe varied as known to the art.

Polymeric films of this invention may be made by dissolving the selectedpolymeric material in a solvent known to the art, e.g., acetone,chloroform or methylene chloride, using about 20 mL solvent per gram ofpolymer. The solution is then degassed, preferably under gentle vacuumto remove dissolved air and poured onto a surface, preferably a flatnon-stick surface such as BYTAC (Trademark of Norton PerformancePlastics, Akron, Ohio) non-stick coated adhesive-backed aluminum foil,glass or TEFLON™. Non-stick polymer. The solution is then dried,preferably air-dried, until it is no longer tacky and the liquid appearsto be gone. The known density of the polymer may be used toback-calculate the volume of solution needed to produce a film of thedesired thickness.

Films may also be made by heat pressing and melt forming/drawing methodsknown to the art. For example, thicker films can be pressed to formthinner films, and can be drawn out after heating and pulled over formsof the desired shapes, or pulled against a mold by vacuum pressure.

The amount of CGRP to be incorporated into the polymeric films of thisinvention is an amount effective to show a measurable effect in treatingof preventing HF and/or renal failure. CGRP can be incorporated into thefilm by various techniques such as by solution methods, suspensionmethods, or melt pressing.

Solid CGRP implants can also be made into various shapes other thanfilms by injection molding or extrusion techniques. For example, theimplant can comprise a core material such as ethylene/vinyl acetatecopolymer, and a vinyl acetate content of 20% by weight or more andwhich functions as a matrix for CGRP, in a quantity which is sufficientfor a controlled release of CGRP, and a membrane which encases the corematerial and also consists of EVA material and an acetate content ofless than 20% by weight. The implant can be obtained, for example, bymeans of a co-axial extrusion process, a method in which the two EVApolymers are extruded co-axially with the aid of a co-axial extrusionhead. The co-axial extrusion process is art known per se so that it willnot be gone into further within the scope of this description.

3. Encapsulated CGRP

Yet another CGRP controlled release formulation according to thisinvention comprises very small capsules which can be administered, forexample by injection, into body tissue of fluids. Accordingly, thisinvention further provides a method of treating HF by administeringcapsules comprising CGRP, and a kit comprising said capsules. Thecapsules include an encapsulating layer which surrounds CGRP orcomprises CGRP dispersed throughout the encapsulating layer. Afterinjection, the encapsulating layer degrades or dissolves, and CGRP isreleased within the heart. CGRP can also diffuse through theencapsulating layer. The encapsulating layer may be made from variousmaterials including biodegradable polymers in the form of microspheres,or from standard vesicle forming lipids which form liposomes andmicelles. Such sustained release CGRP capsules are useful for treatmentor prophylaxis of HF and/or renal failure. Both biodegradable andnonbiodegradable polymers may be used to prepare formulations in whichCGRP is encapsulated within a polymer matrix and surrounded by arate-controlling membrane.

a. Microspheres

One embodiment of CGRP-containing capsules comprises solidmicroparticles formed of the combination of biodegradable polymers withCGRP loadings that yield a sustained release over a period of one day toat least one week, when administered orally, transmucosally, topicallyor by injection. The microparticles have different diameters dependingon their route of administration. For example, microparticlesadministered by injection have diameters sufficiently small to passthrough a needle, in a size range of between 10 and 100 microns. Orallyadministered microparticles are preferably less than 10 microns indiameter to facilitate uptake by the small intestine. The microspherescan contain from less than 0.01% by weight up to approximately 50% byweight CGRP.

As used herein, “micro” refers to a particle having a diameter of fromnanometers to micrometers. Microspheres are solid spherical particles;microparticles are particles of irregular or non-spherical shape. Amicrosphere may have an outer coating of a different composition thanthe material originally used to form the microsphere. Thus, the term“microsphere” as used herein encompasses microparticles, microspheresand microcapsules.

Polymers that can be used to form the microspheres include, but are notlimited to, biodegradable polymers such as poly(lactic-co-glycolic acid)(PLG), poly(lactic acid) (PLA), poly(caprolactone), polycarbonates,polyamides, polyanhydrides, polyamino acids, polyortho esters,polyacetals, polycyanoacrylates and degradable polyurethanes, andcopolymers thereof. Almost any type of polymer can be used provided theappropriate solvent and non-solvent are found which have the desiredmelting points.

Biodegradable microspheres can be prepared using any of the methodsdeveloped for making microspheres for drug delivery, for example, asdescribed by Mathiowitz and Langer (J. Controlled Release, 5:13-22(1987)); Mathiowitz, et al. (Reactive Polymers, 6: 275-283 (1987)); andMathiowitz, et al. (J. Appl. Polymer Sci., 35:755-774 (1988)), theteachings of which are incorporated herein. The selection of the methoddepends on the polymer selection, the size, external morphology, andcrystallinity that is desired, as described, for example, by Mathiowitz,et al. (Scanning Microscopy, 4:329-340 (1990)); Mathiowitz, et al. (J.Appl. Polymer Sci., 45:125-134 (1992)); and Benita, et al. (J. Pharm.Sci. 73:1721-1724 (1984)), the teachings of which are incorporatedherein. Methods include solvent evaporation, phase separation, spraydrying, and hot melt encapsulation. U.S. Pat. Nos. 3,773,919; 3,737,337;3,523,906; 4,272,398; 5,019,400; 5,271,961 and 6,403,114 arerepresentative of methods for making microspheres, each of which isspecifically incorporated herein by reference. U.S. Pat. No. 5,019,400,which is incorporated herein by reference, describes the Prolease®process in which microspheres can be formed in a size suitable forinjection through a 26-gauge needle (less than 50 micrometers indiameter). The process described in U.S. Pat. No. 5,019,400 has theadvantage of achieving drug encapsulation in the absence of water atvery low temperatures. These conditions are particularly suitable forfragile macromolecules such as proteins, where maintaining stability isa concern. Microparticles can be formed by either a continuous freezingand extraction process or by a batch process wherein a batch of frozenmicrodroplets is formed in a first step, and then in a separate secondstep, the frozen microdroplets in the batch are extracted to formmicroparticles. U.S. Pat. No. 6,403,114 describes a method of preparingmicrospheres in commercial batch sizes, and U.S. Pat. No. 5,271,961describes a continuous method of preparing microspheres. Each of thesepatents are incorporated herein by reference

In general, microspheres can be prepared by combining CGRP, the polymerand a solvent to form a droplet, and then removing the solvent to yieldmicrospheres that are hardened, dried, and collected as a free-flowingpowder. Prior to administration to the patient, the powder is suspendedin a diluent and then injected into the patient. Release of CGRP fromthe microsphere is governed by diffusion of CGRP through the polymermatrix and by biodegradation of the polymer. The release kinetics can bemodulated through a number of formulation and fabrication variablesincluding polymer characteristics and the addition of excipients andrelease modifiers. In solvent evaporation, described in U.S. Pat. No.4,272,398, which is incorporated herein by reference, the polymer isdissolved in a volatile organic solvent. The CGRP, either in solubleform or dispersed as fine particles, is added to the polymer solution,and the mixture is suspended in an aqueous phase that contains a surfaceactive agent such as poly(vinyl alcohol). The resulting emulsion isstirred until most of the organic solvent evaporates, leaving solidmicrospheres. After loading the solution with CGRP, the solution issuspended in distilled water containing 1% (w/v) poly(vinyl alcohol),after which the solvent is evaporated and resulting microspheres aredried overnight in a lyophilizer. Microspheres with different sizes(1-1000 microns) and morphologies can be obtained by this method whichis useful for relatively stable polymers such as polyesters andpolystyrene.

Polymer hydrolysis is accelerated at acidic or basic pH's and thus theinclusion of acidic or basic excipients can be used to modulate thepolymer erosion or degradation rate. The excipients can be added asparticulates, can be mixed with the incorporated CGRP or can bedissolved within the polymer.

Degradation modulators can also be added to the microparticleformulation, and the amount added is based on weight relative to thepolymer weight. They can be added to the formulation as a separate phase(i.e., as particulates) or can be codissolved in the polymer phasedepending on the compound. In all cases the amount of enhancer added ispreferably between 0.1 and thirty percent (w/w, polymer). Types ofdegradation modulators include inorganic acids such as ammonium sulfateand ammonium chloride, organic acids such as citric acid, benzoic acids,heparin, and ascorbic acid, inorganic bases such as sodium carbonate,potassium carbonate, calcium carbonate, zinc carbonate, and zinchydroxide, and organic bases such as protamine sulfate, spermine,choline, ethanolamine, diethanolamine, and triethanolamine andsurfactants such as Tween™ and Pluronic™.

Stabilizers can be also added to the formulations to maintain thepotency of CGRP depending on the duration of release. Stabilizersinclude carbohydrates, amino acids, fatty acids, and surfactants and areknown to those skilled in the art. In addition, excipients which modifythe solubility of CGRP such as salts, complexing agents (albumin,protamine) can be used to control the release rate of the protein fromthe microparticles.

In one embodiment for the treatment or prophylaxis of HF and/or renalfailure, the patient is administered CGRP incorporated in microparticleswhich degrade over a period of 1 of 2 months. The microparticlespreferably range in size from 10 to 60 microns, and can be injectedusing a puncture needle with the aid of a suspension media. One exampleof a suspension media comprises 3% methyl cellulose, 4% mannitol, and0.1% Tween™ 80.

In a further embodiment, microparticles containing CGRP can be embeddedin a gel matrix as described in U.S. Pat. No. 6,589,549, which isincorporated herein by reference. In this embodiment, CGRP (alone or incombination with one or more additional agents) may be located in themicroparticle alone or both in the microparticle and the gel matrix. Themicroparticle-gel delivery system can release CGRP over a prolongedperiod of time, at a relatively constant rate. The release profile ofthe system can be modified by altering the microparticle and/or the gelcomposition. After injection, the gel sets and localizes themicroparticle suspended in it. CGRP encapsulated in the microparticlemust be released from the microparticle before traveling through the gelmatrix and entering the biological system. Therefore, the immediaterelease, or the burst, associated with microparticle delivery systemscan be reduced and modulated. Since the release rates of CGRP from thesetwo systems can be quite different, embedding microparticles in the gelphase offers additional modulation and economical use of CGRP. Thebenefits include higher bioavailability and longer duration of actionthan either system when used alone. Moreover, the combined system canimprove the safety of microparticle dosage form. A suitable polymericgel for use in this embodiment comprises ABA-or BAB-type blockcopolymers, where the A-blocks are relatively hydrophobic A polymerblocks comprising a biodegradable polyester, and the B-blocks arerelatively hydrophilic B polymer blocks comprising polyethylene glycol(PEG). The A block is preferably a biodegradable polyester synthesizedfrom monomers selected from the group consisting of D,L-lactide,D-lactide, L-lactide, D,L-lactic acid, D-lactic acid, L-lactic acid,glycolide, glycolic acid, ε-caprolactone, ε-hydroxyhexanoicλ-hydroxybutyric acid, δ-valerolactone, δ-hydroxyvaleric acid,hydroxybutyric acids, malic acid, and copolymers thereof, and the Bblock is PEG. The polymeric gel is preferably biodegradable and exhibitswater solubility at low temperatures and undergoes reversible thermalgelation at physiological mammalian body temperatures. Furthermore,these polymeric gels are biocompatible and capable of releasing CGRPentrained within its matrix over time and in a controlled manner. Thepolymeric gel may be prepared as disclosed in U.S. Pat. No. 6,201,072,which is incorporated herein by reference.

b. Solid Implants

Solid implants made by injection molding or extrusion method similar tothat used to manufacture Norplant™, a product brand and a trademark ofLeiras Co., which is based on a non-degradable polymeric material. Inthis embodiment, a definitely formed device constructed of siliconerubber which is implanted into the body by a surgical operation, and itis removed therefrom in a similar manner after a defined time when theactive component has been released and diffused to the body. Any of thepolymeric materials utilized for the construction of implantable devicesmay be used in the practice of the invention. A broad class of siliconeelastomers can be used to form the silicone-elastomer drug matrix.Suitable silicone elastomers in accordance with the present inventioninclude SILASTIC™ and R-2602 RTV silicone elastomer available from NusilSilicone Technology (Carpinteria, Calif.). The silicone elastomers canbe catalyzed so that polymerization and formation of the core isaccomplished at room temperature. The core may also be formed by heatcurable core material. Generally, the silicone implantable depots areconstructed of polydimethylsilicone (PDMS). See, for example, U.S. Pat.Nos. 4,957,119 and 5,088,505, which are incorporated herein byreference. A typical material is dimethylpolysiloxane (Silgel™ 601,Wacker Chemie GmbH), an addition cross-linking two-component compositionof nine pats of component A and one part of component B.Dimethyldiphenylpolysiloxane, dimethylpolysiloxanol or siliconecopolymers may also be employed. Other suitable polymeric materials arethe porous, ethylene/vinyl acetate copolymers which have been utilizedto construct depots for the implantable release of hydrophilicbiologically active substances such as proteins through the poresthereof. Biodegradable polymers may also be used to form the solidimplants using extrusion or injection molding processes.

c. Liposomes

Another method of delivering CGRP to a patient is accomplished withencapsulation by liposomes, wherein CGRP may be sequestered in theliposome membrane or may be encapsulated in the aqueous interior of thevesicle. The term “liposome” refers to an approximately sphericallyshaped bilayer structure, or vesicle, comprised of a natural orsynthetic phospholipid membrane or membranes that contain twohydrophobic tails consisting of fatty acid chains, and sometimes othermembrane components such as cholesterol and protein, which can act as aphysical reservoir for CGRP. Upon exposure to water, the phospholipidmolecules spontaneously align to form spherical, bilayer membranes withthe lipophilic ends of the molecules in each layer associated in thecenter of the membrane and the opposing polar ends forming therespective inner and outer surface of the bilayer membrane(s). Thus,each side of the membrane presents a hydrophilic surface while theinterior of the membrane comprises a lipophilic medium. These membranesmay be arranged in a series of concentric, spherical membranes separatedby thin strata of water around an internal aqueous space. Thesemultilamellar vesicles (MLV) can be converted into small or unilamellarvesicles (UV), with the application of a shearing force. Liposomes arecharacterized according to size and number of membrane bilayers. Vesiclediameters can be large (>200 nm) or small (<50 nm) and the bilayer canhave unilamellar, oligolamellar, or multilamellar membrane.

The selection of lipids is generally guided by considerations ofliposome size and ease of liposome sizing, and lipid and CGRP releaserates from the site of liposome delivery. Typically, the majorphospholipid components in the liposomes are phosphatidylcholine (PC),phosphatidylglycerol (PG), phosphatidyl serine (PS),phosphatidylinositol (PI) or egg yolk lecithin (EYL). PC, PG, PS, and PIhaving a variety of acyl chains groups or varying chain lengths arecommercially available, or may be isolated or synthesized by knowntechniques.

Current methods of drug delivery by liposomes require that the liposomecarrier will ultimately become permeable and release the encapsulateddrug. This can be accomplished in a passive manner in which the liposomemembrane degrades over time through the action of agents in the body.Every liposome composition will have a characteristic half-life in thecirculation or at other sites in the body. In contrast to passive drugrelease, active drug release involves using an agent to induce apermeability change in the liposome vesicle. In addition, liposomemembranes can be made which become destabilized when the environmentbecomes destabilized near the liposome membrane (Proc. Nat. Acad. Sci.,84:7851 (1987); Biochemistry, 28:9508, (1989)). For example, whenliposomes are endocytosed by a target cell they can be routed to acidicendosomes which will destabilize the liposomes and result in drugrelease. Alternatively, the liposome membrane can be chemically modifiedsuch that an enzyme is placed as a coating on the membrane which slowlydestabilizes the liposome (The FASEB Journal, 4:2544 (1990)). It is alsowell known that lipid components of liposomes promote peroxidative andfree radical reactions which cause progressive degradation of theliposomes, and has been described in U.S. Pat. No. 4,797,285. The extentof free radical damage can be reduced by the addition of a protectiveagent such as a lipophilic free radical quencher is added to the lipidcomponents in preparing the liposomes. Such protectors of liposome arealso described in U.S. Pat. No. 5,190,761, which also describes methodsand references for standard liposome preparation and sizing by a numberof techniques. Protectors of liposomal integrity will increase the timecourse of delivery and provide for increased transit time within thetarget tissue.

Liposomes for use in the present invention can be prepared by any of thevarious techniques presently known in the art. Typically, they areprepared from a phospholipid, for example, distearoylphosphatidylcholine, and may include other materials such as neutrallipids, for example, cholesterol, and also surface modifiers such aspositively charged (e.g., sterylamine or aminomannose or aminomannitolderivatives of cholesterol) or negatively charged (e.g., diacetylphosphate, phosphatidyl glycerol) compounds. Multilamellar liposomes canbe formed by conventional techniques, that is, by depositing a selectedlipid on the inside wall of a suitable container or vessel by dissolvingthe lipid in an appropriate solvent, and then evaporating the solvent toleave a thin film on the inside of the vessel or by spray drying. Anaqueous phase is then added to the vessel with a swirling or vortexingmotion which results in the formation of MLVs. UVs can then be formed byhomogenization, sonication or extrusion (through filters) of MLV's. Inaddition, UVs can be formed by detergent removal techniques

The liposomes containing CGRP can be delivered within biodegradablemicrodrug delivery systems such as larger more stable liposomes or otherfully encapsulated controlled release system, such as a biodegradableimpermeable polymer coatings. The time course of release is governedthen by the additive time delay of the barriers that separate CGRP fromthe host, as well as their combined transport pathways. Microspheredelivery systems could also be used.

4. CGRP Conjugates

A further aspect of this invention includes CGRP conjugated to polymers,and to methods of treating HF and/or renal failure by administering aCGRP conjugate to a patient. It is known that many potentiallytherapeutic proteins have been found to have a short half life in theblood serum. For the most part, proteins are cleared from the serumthrough the kidneys. Small molecules that normally would be excretedthrough the kidneys are maintained in the blood stream if their size isincreased by attaching a biocompatible polymer such as a PEG derivative.Proteins and other substances that create an immune response wheninjected can be hidden to some degree from the immune system by couplingof a polymer to the protein. Accordingly, another embodiment of thisinvention comprises a method of treating HF by administering a conjugatecomprising CGRP coupled to a biocompatible, non-immunogenic polymer. Asused herein, the term “conjugate” refers to a CGRP molecule covalentlyor noncovalently coupled to one or more polymers. These conjugates aresubstantially non-immunogenic and retain at least 75%, preferably 85%,and more preferably 95% or more of the activity of unmodified CGRP.

Examples of polymers that can be coupled to CGRP include, but notlimited to, biological polymers (e.g., polysaccharides, polyamides,pharmacologically inert nucleotide components, etc.), and derivatives ofbiological polymers, or non-biological polymers. Specific examplesinclude poly(alkylene glycols) such as poly(ethylene glycol) (PEG),poly-lactic acid (PLA), poly-glycolic acid, poly(ε-caprolactone),poly(β-hydroxybutyrate), poly(β-hydroxyvalerate), polydioxanone,poly(malic acid), poly(tartronic acid), poly(ortho esters),polyanhydrides, polycyanoacrylates, poly(phosphoesters),polyphosphazenes, hyaluronidate, polysulfones, polyacrylamides,polymethacrylate, chimeric recombinant elastin-silk protein (ProteinPolymers, Inc.) and collagen (Matrix Pharmaceuticals, Inc.). In apreferred embodiment CGRP is conjugated to PEG or a polysaccharide.

As used herein the term “PEG” includes to straight or branchedpolyethylene glycol oligomer and monomers (PEG subunits) and alsoincludes polyethylene glycol oligomers that have been modified toinclude groups which do not eliminate the amphiphilic properties of sucholigomer, e.g. without limitation, alkyl, lower alkyl, aryl, amino-alkyland amino-aryl. The term “PEG subunit” refers to a single polyethyleneglycol unit, i.e., —(CH₂CH₂O)—.

Reactive sites that form the loci for attachment of polymers to CGRP aredictated by the protein's structure. Many polymers react with freeprimary amino groups or thiol groups of the polypeptide. Covalentattachment of the polymers to CGRP may be accomplished by known chemicalsynthesis techniques. In one embodiment of the invention, CGRP may beconjugated via a biologically stable, nontoxic, covalent linkage to oneor more strands of PEG. Such linkages may include urethane (carbamate)linkages, secondary amine linkages, and amide linkages. Variousactivated PEGs suitable for such conjugation are available commerciallyfrom Shearwater Polymers, Huntsville, Ala.

5. Transdermal Delivery

CGRP may also be administered to a patient via transdermal deliverydevices, patches, electrophoretic devices, bandages, and the like. Suchtransdermal patches may be used to provide continuous or discontinuousinfusion of CGRP in controlled amounts. The construction and use oftransdermal patches for the delivery of pharmaceutical agents is wellknown in the art. See, for example, U.S. Pat. No. 5,023,252, thedisclosure of which is herein incorporated by reference. Such patchesmay be constructed for continuous, pulsatile, or on-demand delivery ofCGRP. For example, a dose of CGRP or a pharmaceutically acceptablecomposition thereof may be combined with skin penetration enhancersincluding, but not limited to, oleic acid, oleyl alcohol, long chainfatty acids, propylene glycol, polyethylene glycol, isopropanol,ethoxydiglycol, sodium xylene sulfonate, ethanol, N-methylpyrrolidone,laurocapram, alkanecarboxylic acids, dimethylsulfoxide, polar lipids,N-methyl-2-pyrrolidone, and the like, which increase the permeability ofthe skin to the dose of CGRP and permit the dose of CGRP to penetratethrough the skin and into the bloodstream. CGRP or a pharmaceuticallyacceptable composition thereof may be combined one or more agentsincluding, but not limited to, alcohols, moisturizers, humectants, oils,emulsifiers, thickeners, thinners, surface active agents, fragrances,preservatives, antioxidants, vitamins, or minerals. CGRP or apharmaceutically acceptable composition thereof may also be combinedwith a polymeric substance including, but not limited to,ethylcellulose, hydroxypropyl cellulose, ethylene/vinylacetate,polyvinyl pyrrolidone, and the like, to provide the composition in gelform, which may be dissolved in solvent such as methylene chloride,evaporated to the desired viscosity, and then applied to backingmaterial to provide a patch. The backing can be any of the conventionalmaterials such as polyethylene, ethyl-vinyl acetate copolymer,polyurethane and the like.

6. Transmucosal Delivery

CGRP may also be administered transmucosally, i.e., to and across amucosal surface, for example, for the treatment of angina. Transmucosaladministration of a source of CGRP or a pharmaceutically acceptablecomposition thereof can be accomplished generally by contacting anintact mucous membrane with a source of CGRP or a pharmaceuticallyacceptable composition thereof, and maintaining the source in contactwith the mucous membrane for a sufficient time period to induce thedesired therapeutic effect. Preferably CGRP or a pharmaceuticallyacceptable composition thereof is administered to the oral or nasalmucosa such as the buccal mucosa, the sublingual mucosa, the sinuidalmucosa, the gum, or the inner lip. Particularly, the source of CGRP isany preparation usable in oral, nasal, sinuidal, rectal or vaginalcavities that can be formulated using conventional techniques well knownin the art. For example, the preparation can be a buccal tablet, asublingual tablet, a spray, and the like that dissolves ordisintegrates, delivering drug into the mouth of the patient. A spray ordrops can also be used to deliver the CGRP or a pharmaceuticallyacceptable composition thereof to nasal or sinuidal cavities. Thepreparation may or may not deliver the drug in a sustained fashion.Examples for manufacturing such preparations are disclosed, for example,in U.S. Pat. No. 4,764,378, which is specifically incorporated herein byreference. The preparation can also be a syrup that adheres to themucous membrane. Suitable mucoadhesives include those well known in theart such as polyacrylic acids, preferably having the molecular weightbetween from about 450,000 to about 4,000,000, e.g. Carbopol™ 934P;sodium carboxymethylcellulose (NaCMC), hydroxypropylmethylcellulose(HPMC), e.g. Methocel™ K100, and hydroxypropylcellulose.

The transmucosal preparation can also be in the form of a bandage,patch, and the like that contains the drug and adheres to a mucosalsurface. A mucoadhesive preparation is one that upon contact with intactmucous membrane adheres to the mucous membrane for a sufficient timeperiod to induce the desired therapeutic effect. Suitable transmucosalpatches are described for example in PCT Publication WO 93/23011, whichis specifically incorporated herein by reference. A suitable patch maycomprise a backing which can be any flexible film that prevents bulkfluid flow and provides a barrier for to loss of the drug from thepatch. The backing can be any conventional material such aspolyethylene, ethyl-vinyl acetate copolymer, polyurethane and the like.In a patch involving a matrix which is not itself a mucoadhesive, thedrug-containing matrix can be coupled with a mucoadhesive component(such as a mucoadhesive described above) in order that the patch may beretained on the mucosal surface. Suitable configurations include a patchor device wherein the matrix has a smaller periphery than the backinglayer such that a portion of the backing layer extends outward from theperiphery of the matrix. A mucoadhesive layer covers the outwardextending portion of the backing layer such that the underside of thebacking layer carries a layer of mucoadhesive around its periphery. Thebacking and the peripheral ring of mucoadhesive taken together form areservoir which contains a drug-containing matrix (e.g. a tablet, gel orpowder). It may be desirable to incorporate a barrier element betweenthe matrix and the mucoadhesive in order to isolate the mucoadhesivefrom the matrix. The barrier element is preferably substantiallyimpermeable to water and to the mucosal fluids that will be present atintended site of adhesion. A patch or device having such barrier elementcan be hydrated only through a surface that is in contact with themucosa, and it is not hydrated via the reservoir. Such patches can beprepared by general methods well known to those skilled in the art. Thepreparation can also be a gel or film comprising a mucoadhesive matrixas described for example in PCT Publication WO 96/30013, which isspecifically incorporated herein by reference.

7. Implantable Pumps

In another embodiment, CGRP can be suitably administered using animplantable pump, which is particularly applicable for outpatienttreatment. For example, a constant rate pump may be used to provide aconstant, unchanging delivery of CGRP over a period of time.Alternatively, a programmable, variable rate pump may be used if changesto the infusion rate are desired. Constant rate and programmable pumpsare well know in the art and need not be described further.

CGRP may also be released or delivered from an implantable osmoticmini-pump such as that described in U.S. Pat. Nos. 5,728,396, 5,985,305,6,358,247, and 6,544,252, the disclosures of which are specificallyincorporated herein in their entirety. The release rate from an osmoticmini-pump may be modulated with a microporous, fast-response geldisposed in the release orifice for controlled release or targeteddelivery of CGRP. Osmotic pumps are preferred in that they are muchsmaller than the constant rate and programmable pumps.

In one embodiment, the osmotic pump comprises a miniaturedrug-dispensing system that operates like a miniature syringe andreleases minute quantities of concentrated CGRP formulations in acontinuous, consistent flow over months or years. The system isimplanted under the skin and can be as small as 4 mm OD×44 mm in lengthor smaller. Such a system is sold under the trademark DUROS® by ALZACorporation. In brief, such an osmotic delivery system comprises acapsule having an interior that contains the CGRP and an osmotic agent,a semi-permeable body that permits liquid to permeate through the bodyto the osmotic agent, and a piston located within the interior of thecapsule that defines a movable seal within the interior that separatedthe osmotic agent from the CGRP.

Augmentation of Current HF Therapies

A further aspect of this invention provides a method of treating HF byadministering CGRP according to any of the methods disclosed herein toaugment current HF therapies. CGRP can be administered according to anyof the dosing regimes of this invention together with one or moreaddition drugs for HF, wherein CGRP and the additional drug(s) can beadministered together, separately and simultaneously, or separately inany order.

Acute Myocardial Infarction

In the treatment of acute MI, physicians take aggressive action torestore blood flow to the heart to minimize permanent ischemic damage.These treatments take the form of vasodilators (nitroglycerin) andantithrombolytics (streptokinase, tPA), and platelet aggregationinhibitors (gpIIb/IIIa) in the attempt to dilate the coronary arteriesand dissolve the thrombus, and inhibit platelet aggregation. Iftreatment is successful in restoring blood flow, the patient may be sentto recover in the CCU or go to the catheterization lab for anangioplasty or stenting procedure to open any remaining occlusions.However, the ischemic event itself causes generation of free radicals,and this process is potentiated when the vessels are re-opened and bloodflow restored, which results in further tissue damage. In this setting,CGRP therapy administered alone or in conjunction with other therapeuticinterventions according to any of the methods of this invention,particularly the infusion methods, would augment the current therapiessuch as antithrombolytics by elevating the therapeutic benefits of thesedrugs. The cardioprotective benefits of CGRP when infused at the initialstages of evaluation and treatment would provide levels of CGRP suitableto minimize reperfusion injury when interventional therapy is initiated,and thus maximize positive acute and long-term recovery outcomes.

Accordingly, this invention further provides a method of counteractingischemia due to myocardial infarction in a patient, comprisingdelivering to said patient an amount of CGRP effective to providecardioprotection, reduction in infarction size, reduction in reperfusioninjury, symptomatic relief, and/or prevent exacerbation of symptoms,wherein said CGRP is delivered to said patient as a controlled releasecomposition.

Percutaneous Translumenal Coronary Angioplasty (PTCA) and Stenting

If antithrombolytic therapy is ineffectual in the emergency room, or ifit is determined that elective PTCA intervention is required to restoreblood flow, CGRP infusion therapy already in process in the emergencyroom or started in the catheterization lab would provide the samereperfusion benefits as those described above when blood flow isrestored to the ischemic tissues. Additional benefits in thecatheterization lab would be realized when CGRP infusion therapy locallydilates coronary blood vessels, decreases the incidence of vasospams andno-reflow during procedures, increases renal blood flow, and assists inpreventing platelet aggregation and smooth muscle cell proliferation atthe acute time points (<24 hours) following PTCA. Currently, Reopro® orIntegrillin® is administered in advance or during PTCA procedures tohalt platelet aggregation and reduce the incidence of restenosis in thelong-term (>48 hours). CGRP infusion therapy would augment these currentrestenosis therapies by elevating the therapeutic benefits of preventingreperfusion injury, as well as inhibiting platelet aggregation andsmooth muscle cell proliferation in the acute-term (<24 hours).

Coronary Artery Bypass Surgery (CABG)

Whether CABG is performed as an emergency procedure or as electivesurgery, CGRP infusion therapy would provide all of the benefits statedabove with respect to acute MI treatment and PTCA procedures. As aresult, a CABG procedure could potentially experience even greatpositive outcomes and fewer acute-term complications.

Coronary Care Unit (CCU) Recovery

CGRP infusion therapy in CCU patients would maximize the ability of CGRPto reduce infarction size and promote cardiac tissue salvage. Whetherthe therapy was initiated in the emergency room, the cauterization lab,the operating room, or the CCU, recovery and healing process will beginin the CCU where CGRP can be administered over the course of severaldays, and the long-term benefits of CGRP infusion therapy will realized.

Kits

The present invention also provides pharmaceutical kits for treating HFand/or improving renal function, comprising one or more containerscomprising one or more CGRP compositions of this invention. Such kitscan also include additional drugs or therapeutics (e.g.,antiproliferative or anti-clotting agents, or other compounds used totreat cardiovascular diseases and the like) for co-use with CGRP fortreatment or prevention of HF and/or for improving renal failure. Inthis embodiment, the CGRP and the drug can be formulated in admixture inone container, or can be contained in separate containers forsimultaneous or separate administration. The kit can further comprise adevice(s) for administering the compounds and/or compositions, andwritten instructions in a form prescribed by a governmental agencyregulating the manufacture, use or sale of pharmaceuticals or biologicalproducts, which instructions can also reflect approval by the agency ofmanufacture, use or sale for human administration.

The foregoing description is considered as illustrative only of theprinciples of the invention. Further, since numerous modifications andchanges will be readily apparent to those skilled in the art, it is notdesired to limit the invention to the exact construction and processshown as described above. Accordingly, all suitable modifications andequivalents may be resorted to falling within the scope of the inventionas defined by the claims that follow.

The words “comprise,” “comprising,” “include,” “including,” and“includes” when used in this specification and in the following claimsare intended to specify the presence of stated features, integers,components, or steps, but they do not preclude the presence or additionof one or more other features, integers, components, steps, or groupsthereof.

1.-47. (canceled)
 48. A method of counteracting ischemia due to amyocardial infarction in a heart failure patient, comprising the stepsof: (a) identifying a patient that is suffering from heart failure; and(b) delivering a treatment effective amount of a composition comprisingCGRP to the heart failure patient so that ischemia due to a myocardialinfarction in the heart failure patient is counteracted; wherein thecomposition is a flowable thermoplastic polymer composition comprising abiocompatible polymer, a biocompatible solvent and CGRP, and thecomposition is delivered to a bodily tissue or fluid in the patient,wherein the amounts of the polymer and the solvent are effective to forma biodegradable polymer matrix containing CGRP in situ when thecomposition contacts the bodily tissue or fluid.
 49. The method of claim48, wherein the ischemia is counteracted by a reduction in infarctionsize or reduction in reperfusion injury.
 50. The method of claim 48,wherein the composition is delivered to the heart failure patient priorto the myocardial infarction.
 51. The method of claim 48, wherein thecomposition is in the form of a conjugate comprising CGRP coupled to apolymer.
 52. The method of claim 51, wherein the polymer is apoly(alkylene glycol) or a polysaccharide.
 53. The method of claim 48,wherein the composition comprises a controlled release additive.
 54. Themethod of claim 48, wherein the composition comprises between about 0.56and 290 mg CGRP and between about 0.01 and 5.8 mL of the composition isadministered to the patient.
 55. The method of claim 48, wherein thecomposition comprises about 0.56 and 290 mg CGRP and between about 0.004and 1.93 mL of the composition is administered to the patient.
 56. Themethod of claim 48, wherein the biocompatible polymer is selected fromthe group consisting of polylactides, polyglycolides, polyanhydrides,polyorthoesters, polycaprolactones, polyamides, polyurethanes,polyesteramides, polydioxanones, polyacetals, polyketals,polycarbonates, polyorthocarbonates, polyphosphazenes,polyhydroxybutyrates, polyhydroxyvalerates, polyalkylene oxalates,polyacrylates, polyalkylene succinates, poly(malic acid), poly(aminoacids) and copolymers, terpolymers, cellulose diacetate, ethylene vinylalcohol, and copolymers and combinations thereof.
 57. The method ofclaim 48, wherein the polymer matrix releases CGRP by diffusion,erosion, or a combination of diffusion or erosion as the polymer matrixbiodegrades in the patient.
 58. The method of claim 48, wherein the CGRPis delivered via a puncture needle or catheter.
 59. The method of claim48, further comprising administering one or more drugs selected from thegroup consisting of anti-proliferative agents, anti-clotting agents,vasodilators, diuretics, beta-blockers, calcium ion channel blockers,cardioprotectants, blood thinners, cardiotonics, ACE inhibitors,anti-inflammatories, and antioxidants.
 60. The method of claim 59,wherein the drug is added to the polymer composition prior toadministration such that the solid polymer matrix further contains thedrug.
 61. The method of claim 59, wherein the drug is administered as aseparate formulation before, simultaneously with, or subsequently toadministration of the polymer composition.
 62. The method of claim 48,wherein the controlled release composition comprises biodegradablemicrospheres incorporating CGRP.
 63. The method of claim 62, wherein themicrospheres comprise poly(lactic-co-glycolic acid), poly(lactic acid),poly(caprolactone), polycarbonates, polyamides, polyanhydrides,polyamino acids, polyortho esters, polyacetals, polycyanoacrylatesdegradable polyurethanes, polyacrylates, ethylene-vinyl acetatecopolymers, acyl substituted cellulose acetates, and derivatives andcopolymers thereof.